I LIBRARY OF CONGRESS, 



Mlmg. A.:.rl. fcgtijM po. 

| ^%.ef Life: 

! UNITED STATES OF AMERICA. 



LECTURES 



ON 



IEVEES 



ALFRED L. LOOMIS, A.M., M.D.. 



/ 
& 



PROFESSOR OF PATHOLOGY AND PRACTICAL MEDICINE IN THE MEDICAL DEPARTMENT OF THE 

UNIVERSITY OF THE CITY OF NEW YORK ', CONSULTING PHYSICIAN TO THE CHARITY HOSPITAL 

— TO THE BUREAU OF OUT-DOOR RELIEF — TO THE NORTH-WESTERN DISPENSARY — 

TO THE CENTRAL DISPENSARY ; LATE VISITING PHYSICIAN TO THE 

BLACKWELL'S ISLAND FEVER HOSPITAL ; VISITING PHYSICIAN TO 

BELLEVUE HOSPITAL — TO THE MOUNT SINAI HOSPITAL, 

ETC., ETC. 



fctf 



NEW YORK: 
WILLIAM WOOD & COMPANY 

27 Great Jones Street. 

1877. 



COPYKIGHT, BY 

WILLIAM WOOD & CO. 

1877. 



Tkow's 

Printing and Bookbinding Co., 

printers and bookbinders, 

205-213 East \2tk St.. 
NEW YORK. 



ALUMNI AND STUDENTS 

OF THE 

MEDICAL DEPARTMENT OF THE UNIVERSITY OF THE CITY OF XEW YORK, 

THESE LECTURES ARE DEDICATED 

BY THEIR SINCERE FRIEND, 
THE AUTHOR. 



PREFACE. 



These lectures were delivered in the Medical Department 
of the University of the City of New York, to the Class of 
1876-77. 

With unimportant alterations, I now offer them as they 
were phonographically reported by Dr. Wm. M. Carpenter. 

As in the preparation of my "Lectures on Diseases of 
the Lungs, Heart, and Kidneys," it has been my custom, 
after careful reading and close analysis of the subject of 
each lecture, to trust that the stimulus of the class would 
enable me to present the most recent views of acknowledged 
authorities, combined with the results of my own clinical 
observation and experience, in so simple, intelligible, and 
concise a manner that each student might master the prom- 
inent points. 

I have adopted an etiological basis in the classification 
of fevers, and have endeavored to include in a few gen- 
eral classes all the numerous types described by different 
writers. 

I have referred to theoretical questions only so far as was 
necessary in order to the proper understanding of subjects 
under consideration. 

The Bibliography which accompanies these lectures in- 
cludes those books, monographs, and theses which have 
been published since 1850, nearly all of which have been 
written, or are in circulation, in this country. 

A few old books have been referred to, because they con- 



VI PEEFACE. 

tain many of the so-called new theories and modes of treat- 
ing fevers. 

My aim has been to give a summary of the literature of 
fevers in this country, and so much of foreign literature 
upon this subject as might be of interest and service to the 
student who desires to thoroughly investigate the subject 
of fevers. No notice has been taken of papers which have 
only appeared in medical journals. 

These lectures are the result of careful study of the litera- 
ture referred to in the Bibliography, combined with exten- 
sive clinical experience. 

I have endeavored to be unbiassed in my statements of 
facts. 

It is my purpose at some future time to publish, in similar 
form, lectures upon other infectious diseases. 

42 West Twenty-fifth Street, August, 1877. 



CONTENTS. 



LECTURE I. 

FEVERS. 



PAGE 

Introduction — Classification — Typhoid Fever — Morbid Anatomy 1 



LECTURE II. 

TYPHOID FEVER. 

Morbid Anatomy (continued) — Intestinal Lesions — Etiology 14 

LECTURE III. 

TYPHOID FEVER. 

Symptoms . 27 

LECTURE IV. 

TYPHOID FEVER. 

Symptoms (continued) — Differential Diagnosis „ 39 

LECTURE V. 

TYPHOID FEVER. 

Prognosis — Duration— Relapses 50 

LECTURE VI. 

TYPHOID FEVER. 
Treatment 61 

LECTURE VII. 

TYPHOID FEVER. 
Treatment (continued). ...... 71 



Vlll CONTENTS. 

LECTURE VIII. 

YELLOW FEVER. 

PAGE 

Morbid Anatomy — Etiology — Symptoms 85 

LECTURE IX. 

YELLOW FEVER. 

Symptoms (continued) — Differential Diagnosis — Prognosis — Treatment 95 

LECTURE X. 

MALARIAL FEVERS. 

Introduction 109 

LECTURE XI. 

SIMPLE INTERMITTENT FEVER. 

Morbid Anatomy — Etiology — Symptoms — Differential Diagnosis — Prognosis 

—Treatment , 119 

LECTURE XII. 

SIMPLE REMITTENT FEVER. 

Morbid Anatomy — Etiology — Symptoms— Differential Diagnosis — Prognosis. 132 

LECTURE XIII. 

PERNICIOUS FEVER. 

Treatment of Simple Remittent Fever — Morbid Anatomy — Etiology — 

Symptoms 145 

LECTURE XIV. 

PERNICIOUS FEVER. 

Symptoms (continued) — Differential Diagnosis — Prognosis — Treatment 157 

LECTURE XV. 

DENGUE FEVER. 

Morbid Anatomy — Etiology— Symptoms — Differential Diagnosis — Treatment 

— Chronic Malarial Infection c . . 169 

LECTURE XVI. 

TYPHO-MALARIAL FEVER. 

Introduction — Morbid Anatomy —Etiology — Symptoms « 181 



CONTENTS. - IX 

LECTURE XVII. 

TYPHO-MALARIAL FEVER. 

PAGE 

Symptoms (continued)— Differential Diagnosis— Prognosis—Treatment 190 



LECTURE XVIII. 

TYPHUS FEVER. 

Introduction — Morbid Anatomy — Etiology 205 

LECTURE XIX. 

TYPHUS FEVER. 

Symptoms 217 

LECTURE XX. 

TYPHUS FEVER. 

Symptoms (continued) — Differential Diagnosis — Prognosis . . .. 229 

LECTURE XXI. 

TYPHUS FEVER. 

Treatment 243 

LECTURE XXII. 

RELAPSING FEVER. 

Morbid Anatomy — Etiology — Symptoms — Differential Diagnosis — Treatment. 256 
LECTURE XXIII. 

EXANTHEMATOUS FEVERS. 

Small-Pox — Morbid Anatomy — Etiology — Symptoms 268 

LECTURE XXIV. 

SMALL-POX. 

Symptoms (continued) — Differential Diagnosis— Prognosis 280 

LECTURE XXV. 

SMALL-POX. 

Treatment (continued) — Inoculation — Vaccination — Varioloid 293 



X CONTENTS. 

LECTUEE XXVI. 

SCAKLET FEVER. 

PAGE 

Introduction — Morbid Anatomy — Etiology — Symptoms 304 

LECTURE XXVII. 

SCARLET FEVER. 

Symptoms (continued) — Complications — Sequetee 315 

LECTURE XXVIII. 

SCARLET FEVER. 

Differential Diagnosis — Prognosis— Treatment 326 

LECTURE XXLX. 

MEASLES. 

Morbid Anatomy — Etiology — Symptoms 337 

LECTURE XXX. 

MEASLES. 

Differential Diagnosis — Prognosis — Treatment — Roseola — Miliary Fever 348 



MIASMATIC-CONTAGIOUS 
FEVERS. 



LECTURE I 



FEVERS. 



Introduction. — Classification. — Typhoid Fever. — Morbid 

Anatomy. 

Gentlemen : — We will commence this course of lectures 
with the study of those diseases which depend upon morbid 
conditions of the blood, produced by morbific agents de- 
veloped exterior to the body of the affected. Such mor- 
bific agents may give rise, either directly or indirectly, to 
morbid processes ; either by the changes which they pro- 
duce in the blood, or by their action on the different organs 
and tissues of the body to which they are conveyed by the 
blood-vessels and lymphatics. 

The class of morbific agents which will now especially en- 
gage our attention may be included under the general head 
of viruses. 

By the term virus. I mean a morbific substance which is 
developed either from animal or vegetable tissues in the 
process of decomposition, or from the excretions of diseased 
living beings. Many viruses are volatile, and may be con- 
veyed either by air, by fluids, or by solids, and when so 
conveyed they become the means by which diseases known 
as contagious or infectious are transmitted. Some viruses 
are palpable poisons, and may be transmitted from the dis- 
eased to the healthy by inoculation. 

When the virus which gives rise to a disease has its origin 
only in a living being, from whom it is excreted in an active 



a INTRODUCTION. 

state, capable of conveyance from one person to another, 
then the disease which it produces is called contagious, and 
the virus is called a contagion. 

If the morbific agent which has the power of developing 
disease has originated from decomposing organic matter, 
and has been diffused through the air or water, so that 
infection may have resulted without contact with one al- 
ready diseased, the disease is called miasmatic, and the 
virus is called a miasm. For instance, intermittent fever 
is a miasmatic disease, while small-pox and measles are 
contagious diseases. 

With our present knowledge of the nature and origin of 
viruses, we can make no classification, except that which 
is based on their differences of action. We speak of 
typhus, typhoid, and malarial poisons, but these different 
poisons have as yet no known physical or chemical proper- 
ties by which we are able to distinguish one from another. 
We can only recognize their presence by the peculiar mor- 
bid phenomena which each has the power of developing in 
the animal economy. 

The different diseases which are developed by the morbid 
processes excited by these different viruses are, at the pres- 
ent time, classed under the head of infectious diseases, and 
the influence of these viruses upon the body is called infec- 
tion. It is also important for you to remember that all of 
those diseases which are included under the general head 
of infectious diseases have their own specific morbid pro- 
duct, which will produce these, and only these, diseases ; 
and although these different diseases may have very many 
symptoms in common, and may very closely resemble each 
other in the phenomena which attend their development, 
yet the specific character of the morbific agent which has 
produced them stamps them as distinct diseases. There is 
reason to believe that not one of this class is of spontaneous 
origin, but that each depends on its own specific poison. 
As to the exact nature of such a poison, and its element of 
power in the production of disease, we have no positive 
knowledge ; at the present time, in regard to it, there are 
two prominent theories. 



lOTEODUCTIOlS". 6 

The first is based upon chemical processes ; the second, 
upon the multiplication of living organisms. 

The chemical theory maintains that after the infectious 
element has been received into the blood it acts as a fer- 
ment, and gives rise to certain morbid processes upon the 
principle of catalysis. 

The theory of organisms, or the germ theory, as it is 
called, maintains that the infectious poisons are living 
organisms, which, being received into the blood, reproduce 
themselves indefinitely, and by their reproduction morbid 
processes are excited which are characteristic of certain 
types of disease. This is a very seductive theory, and at 
the present time is quite extensively adopted by medical 
theorists, as it so readily explains very many remarkable 
facts connected with the development and reproduction of 
the class of diseases which are soon to engage our atten- 
tion. It is readily understood, and there are so many ani- 
mal poisons which appear to act in this manner, that to one 
whose opinions are not based upon clinical experience and 
actual contact with disease, the arguments in its favor seem 
conclusive. 

According to this theory all the different forms of disease 
included under the head of contagious or infectious may 
be reduced to, or embraced in, two classes : 

First, infectious diseases which depend for their devel- 
opment upon a living animal organism. Second, those 
which depend for their production upon a living vegetable 
organism. Unfortunately for this theory, the special or- 
ganism of any one of the infectious diseases has never been 
so plainly described by any one competent observer that all 
others in the same field of study could with certainty recog- 
nize it. The bacterian theory, which recently has so occu- 
pied the attention of medical men, especially in Germany, 
is rapidly being disproved, and consequently as rapidly 
being abandoned. In this country it can scarcely be held 
to have ever gained a foothold. It seems to me that one 
who has watched bacterian development must arrive at the 
conclusion that bacteria found in connection with the de- 
velopment of disease are the product and not the cause of 



4 INTRODUCTION. 

the diseased process ; certain it is that the theory that there 
exists distinct typhoid, typhus, and diphtheritic living 
germs, which are the propagating element of these different 
diseases, still lacks that proof which will lead the practical 
physician to adopt it. The question then comes back to 
us, what is the real nature of those morbific substances 
which, when received into the human organism, have the 
power of manifesting phenomena which characterize that 
class of disease which we term infectious? Every day's 
experience must convince the careful observer that each 
one of this class of diseases has a distinct producing cause 
— that the poison of typhus will not produce typhoid 
fever, neither will the poison of measles develop scarlatina. 
Although the phenomena which attend the development of 
these differing diseases may have many points of resem- 
blance, yet each has a distinct origin, that is, has its own 
specific infection, which specific morbific substance, when- 
ever introduced into the animal economy, either through 
the skin, respiratory organs, or digestive surfaces, interferes 
in a greater or less degree with the functions of organic 
life. This interference is caused either by changes which it 
produces in the constituents of the blood, or in the solid 
organs and tissues to which it is conveyed by the blood- 
vessels and lymphatics. 

After reviewing these differing theories and giving careful 
attention to the facts presented in their support, we arrive 
at this conclusion — that the exact nature of these morbific 
agents is unknown. We know that they exist, from the dis- 
eased action which they produce ; and from the manner in 
which these diseases are propagated we decide that their 
poisons are distinct from all other poisons, and that each is 
specific and can reproduce itself to an unlimited extent. 
The germ theory best explains the phenomena of develop- 
ment. The chemical theory has decided claims on our 
acceptance ; but until our explorations shall have been car- 
ried so far as to determine, beyond question, what is the 
exact nature of several of these poisons, we shall be com- 
pelled to call them unknown morbific agents, governed 
by certain fixed laws of development and propagation. At 



INTRODUCTION. 5 

the present time investigation in this direction has scarcely 
begun. 

As we pass from the general causation of this group of 
diseases to their classification, we find ourselves still in 
doubt. The symptomatic basis of classification of the 
earlier writers gave place to the more scientific and compre- 
hensive anatomical basis of classification. This for a long 
period has been almost universally adopted, yet now is 
giving place to the recent and more definite etiological clas- 
sification of the present day. 

When these diseases are classified upon an etiological 
basis, very naturally they divide themselves into three 
classes. 

First. — A class in which the morbific agent cannot be 
developed exterior to a living being, but, when developed 
within the system of one individual, can be transferred to 
another through the atmosphere. Such is the case in mea- 
sles, small- pox, and typhus fever. 

Second. — We have another class called miasmatic or ma- 
larial diseases, in which the morbific agent is developed 
exterior to a physical organization, and cannot be conveyed 
from one individual to another. 

Third. — There is a class in which the morbific agent is 
developed within, and reproduced exterior to a physical 
organization. In this class, the poison is developed within 
the body, but in order that it may be reproduced it must be 
deposited in decomposing organic matter exterior to the 
body ; it is then rapidly reproduced, and when received into 
a healthy organism gives rise to diseased processes. It can- 
not be directly conveyed from the sick to the healthy, but 
only through the excrements of the sick, or through de- 
composing organic matter exterior to the body, with which 
such excrements must have been in contact. There may 
be all the elements necessary to its reproduction, such 
as decomposing animal and vegetable matter, but the 
disease will not be developed unless there has been added 
to this decomposing mass the specific poison of the disease. 

The diseases thus developed have been called miasmatic- 
contagious, of which typhoid fever is the best example. 



6 CLASSIFICATION OF FEVERS. 

All the different forms of acute contagions-miasmatic or 
miasmatic- contagions disease may be either endemic or epi- 
demic. 

They are epidemic when they attack a large number of 
persons at the same time and in the same manner. 

They are endemic when they are often repeated in the 
same locality. If they attack individuals without regard 
to time and place, they are called sporadic. 

With this brief introduction, we will enter upon the 
study of that class of diseases which during the present 
century have been included under the general head of 
fevers. 

Adopting an etiological basis of classification, I shall 
divide fevers into three classes. 

First. Contagious Fevers. — I shall include under this 
head all those fevers which depend for their development 
on a specific morbific agent, which agent must originate in 
an individual suffering from a like specific disease. 

Second. Miasmatic or Malarial Fevers. — I shall in- 
clude under this heading all those fevers which depend 
for their development on a morbific agent developed exterior 
to the body, and not connected with any previously diseased 
physical organization. 

Tliircl. Miasmatic-Contagious Fevers. — I shall include 
under this head those fevers which depend upon a morbific 
agent developed exterior to the body in animal and vege- 
table decompositions, to which has been added the specific 
poison of the fever which has had its origin in a diseased 
physical organization. 

The following is the classification which I shall adopt : 

classification of fevers. 
First Class. — Contagious. 



Typhus Fever, Relapsing Fever, 

Small-Pox, Scarlet Fever, 

Measles, Miliary Fever. 



CLASSIFICATION OF FEVERS. 7 

Second Class. — Malarial. 
Simple Intermittent Fever, Simple Remittent Fever, 
Pernicious Fever, Dengue Fever, 

Typho-malarial Fever. 

Third Class. —Miasmatic-Contagious. 
Typhoid Fever, Yellow Fever. 

The third class of fevers is a connecting link between the 
first and second class. 

In their pathology and clinical histories the fevers of this 
class have many things in common with those of each of 
the other classes, as also in their origin, nature of poison, 
etc. On this account, and from the fact that during the 
course of every fever some of the phenomena of typhoid 
fever are presented, I shall first describe those fevers in- 
cluded in the third class, and shall commence with typhoid 
fever. 

TYPHOID FEVER. 

This is the most universally prevalent of all fevers. So 
far as we know, there is no place where it may not be 
developed and spread. It more frequently prevails in the 
temperate zone than in the torrid or frigid, but it is possible 
for it to be developed in all latitudes and in all countries. 

This disease, which is essentially the same in all countries, 
is designated by different names. American writers describe 
it under the name of typhoid fever. The French call it the 
typhoid affection, or dothinenteria. English writers describe 
the same form of disease under the head of enteric fever. 
The Germans call it abdominal typhus, or gastric fever. I 
prefer the name typhoid fever, and will commence its his- 
tory by describing its anatomical lesions. 

Morbid Anatomy. — As soon as the disease is fully estab- 
lished a change in the blood occurs. It becomes darker in 
color, coagulating imperfectly, the serum being imperfectly 
separated from the solid constituents, and is of an unnatu- 
rally yellow color. The question arises — did these changes 
take place in the blood prior to the occurrence of the fever, 
between the exposure and the period of attack ? It is cer- 



8 TYPHOID FEVEE. 

tain that as soon as the characteristic symptoms of the dis- 
ease are present, the diminution in the fibrin of the blood 
is in exact proportion to the severity of the fever, and the 
number of white globules is increased in a similar ratio. 

As a consequence of these blood changes, or in connection 
with them, a series of changes takes place in those organs 
and tissues of the body in which the processes of waste and 
repair are most rapidly going on. These changes are of the 
nature of parenchymatous degeneration — the essential con- 
stituents of the affected organs and tissues being involved. 

Similar parenchymatous changes are met with not only 
in typhoid fever, but to a greater or less extent are charac- 
teristic of other fevers and acute infectious diseases. 

Spleen. — The organ in which parenchymatous degenera- 
tion occurs earliest and most extensively is the spleen. 

We find this organ undergoing three distinct changes. 

First. — It is increased in size, sometimes enormously. 
The enlargement commences soon after the beginning of 
the disease, and goes on rapidly until the third week, after 
which it ceases, and after a few days the spleen begins to 
diminish in size. If recovery takes place, by the time it is 
reached the spleen will have returned to its normal size. 

The splenic enlargement is apparently due to congestion 
and to an increase of normal elements. 

Second. — As soon as the spleen reaches its maximum 
size, its consistency becomes soft ; this softening is some- 
times so marked that, if a post-mortem be made at the end 
of the third week, the spleen will present the appearance 
of a dark, jelly-like mass, which is easily broken down. 

Third. — The organ becomes almost black in color, owing 
to the intense congestion which attends its enlargement, 
and to the deposit of a brown pigment in its substance. 

These changes in the spleen take place, in a greater or 
less degree, in ninety-eight cases out of every hundred. 

At. the post-mortem of those who have died of typhoid 
fever, infarctions are sometimes found, although there is 
nothing peculiar about them. In rare instances, rupture of 
the spleen occurs without infarctions. 

Livee. — Changes in the liver are by no means as common 



MORBID ANATOMY. 9 

as those in the spleen. The liver may be found presenting 
its normal appearance, or it may be soft and flabby. When 
soft and flabby, a microscopic examination shows the liver 
cells more or less granular and fatty, the nuclei of the cells 
can no longer be seen, and the degeneration may become so 
extensive that the outline of the hepatic cells is lost, and 
nothing but a mass of granules remain. 

Occasionally there will be found in the liver of those who 
have died of typhoid fever small grayish nodules situated 
along the course of the small veins ; these nodules consist 
of lymphoid cells. 

The lining membrane of the gall-bladder sometimes pre- 
sents evidences of catarrhal or diphtheritic inflammation, 
when there has been no evidence of its existence during 
life ; cases are recorded where it has been found ulcerated. 

Kidneys. — Degenerative changes in the kidneys are of 
not infrequent occurrence in the course of typhoid fever ; 
they vary in extent with the duration and severity of the 
fever. When present, they are more marked in the cortical 
than in the medullary portion of the organ. In some cases 
they are confined to the epithelial elements, while in other 
cases degeneration of all the anatomical elements of the 
organs can be found. Such extensive changes are less lia- 
ble to occur in typhoid than in typhus fever. Small gray 
nodules similar to those referred to as occurring in the liver 
are sometimes found. 

If the epithelial degeneration of the cortical substance is 
extensive, the cells finally break down into a granular 
detritus, and the cut surface assumes a yellow color and is 
softer than normal. Infarctions are sometimes met with in 
the kidneys of those dying of typhoid fever. 

Heart. — The parenchymatous changes which take place 
in the heart are more marked than those in any other or- 
gan, for its anatomical elements undergo waste and repair 
more actively than those of any other organ ; and if faulty 
nutrition is an important element in these degenerative 
changes, this organ must become very markedly involved. 

In a large proportion of cases it becomes soft and flabby, 
and is of a grayish or brown color. Sometimes it is so much 



10 TYPHOID FEVER. 

changed that its tissues are easily broken down by moderate 
pressure ; it loses its normal outline, and when removed 
from the body the walls of its cavities readily fall together. 
When its muscular tissue is examined microscopically, in 
many instances it will be found that granular changes, 
affecting the ultimate muscular fibres, have occurred ; this 
granular muscular degeneration may involve a large por- 
tion of the organ, or it may be confined to a few muscular 
fibres. It may be a general or a localized parenchymatous 
degeneration. Occasionally the muscular fibres are infil- 
trated with brown pigment. 

If, as is sometimes the case, the heart retains its normal 
outline, is friable, and its cut surface glistens, the muscular 
fibres will be found to have undergone a change which closely 
resembles amyloid degeneration ; the muscular fibres will be 
filled with a material which presents the same shining appear- 
ance as the amyloid substance, but on applying the iodine 
test the same reaction does not take place. It is a form of 
degeneration which occurs in typhoid fever and is not 
confined to the muscular tissue of the heart, but is found 
to a greater or less extent in the voluntary muscles of the 
body. 

Thrombi are sometimes found in the heart, and vegeta- 
tions adhering to the valves and chordae tendinese. These 
may give rise to infarctions in the different organs of the 
body. The existence of the degenerative changes in the 
heart, to which I have referred, may be recognized during 
the life of the patient, for the heart sounds become feeble 
according to the extent of the degeneration. In some cases 
the first sound of the heart will be absent, and it has been 
claimed that when this phenomenon is present the use of 
stimulants in large quantities is indicated. 

Lungs. — The lungs undergo changes which have received 
the name of splenization. This is a form of pulmonary 
congestion which has received its name from the close re- 
semblance which the affected portion of lung tissue bears 
to the spleen. 

The affected lung tissue is of a darker color than normal, 
and scattered through its substance will be seen little red 



MORBID ANATOMY. 11 

or yellowish white points ; these little points are scanty 
blood extravasations. 

Lnng tissue in a condition of splenization is of a dark 
reddish blue, brown, or black color ; its consistency is firmer 
than normal, crepitates less freely, has a more uniform, 
homogeneous appearance upon its cut surface, and is less 
moist than normal lung tissue ; a dark fluid will sometimes 
ooze from its cut surface, but not as freely as in hypersemia, 
and the fluid is more watery in appearance. 

A microscopical examination of lung tissue in this condi- 
tion shows the capillary vessels filled with blood, and the 
alveoli containing a variable number of cells. In other 
words, it is a condition closely resembling that condition 
known as static pneumonia, but no inflammatory process 
exists ; it is simply a stasis in the capillary circulation, 
accompanied by a slight increase in the cell elements in the 
alveoli. 

Bronchial Tubes. — You will rarely make an autopsy 
upon one who has died of typhoid fever, without finding 
evidences of a more or less extensive catarrhal inflammation 
affecting the bronchial tubes. So constantly is catarrhal 
bronchitis present in this fever, that Dr. Stokes proposed to 
call typhoid fever bronchial typhus. In most cases this 
catarrh is not extensive, affecting only the larger bronchi ; 
it may, however, extend to the smaller tubes and give rise 
to capillary bronchitis and broncho-pneumonia. Pulmo- 
nary infarctions are frequeutly found in the lungs of those 
who have died of typhoid fever. They are sometimes quite 
numerous, are usually of small size, and vary in appearance 
according to the stage of their development. When recent 
they are of dark color, and feel like consolidated lung tis- 
sue ; later, the color changes to yellow ; they may soften 
and break down. 

Larynx. — The larynx, as well as the bronchial tubes, is 
frequently the seat of catarrhal inflammation ; less fre- 
quently it is the seat of diphtheritic inflammation. In con- 
nection with these laryngeal inflammations, ulcers appear 
in the larynx ; these have received the name of " typhoid 
ulcers of the larynx;" sometimes they give rise to quite 



12 TYPHOID FEVEE. 

extensive hemorrhages. In connection with, or independent 
of these laryngeal ulcers, ulceration of the mucous mem- 
brane of the mouth and pharynx may occur ; at times it 
involves the epiglottis in such a manner as to clip off its 
edges. These ulcers may develop on the mucous membrane 
of the Eustachian tube. In those cases where permanent 
deafness follows an attack of typhoid fever, it will usually 
be found due to ulceration of the mucous membrane of the 
Eustachian tube. 

Brain and Nervous System. — As yet we have not been 
able to determine whether there are any structural changes 
in the brain or nervous system so constant that they may 
be regarded as lesions of typhoid fever, although it is rea- 
sonable to infer that in a disease where such severe func- 
tional disturbances of the cerebro-spinal system exist there 
must be constant and definite parenchymatous changes. 
(Edema of the pia mater and of the brain substance, with 
occasionally quite extensive adhesions of the dura mater to 
the cranium, not infrequently exist. Punctate extravasa- 
tions into brain substance are found in a certain number of 
cases, but even in severe cases they are not always present. 

Stomach. — The changes which occur in the stomach are 
equally important with those that occur in the other inter- 
nal organs, and are degenerative in their nature. Softening 
and degeneration of its glandular structure is sometimes so 
extensive, that if recovery from the fever takes place, a 
very long time must elapse before the organ can perform its 
normal function. It is the existence of these degenerative 
changes that gives rise to the disturbance in digestion which 
is present in so many cases, not only during the continuance 
of the fever, but during convalescence. 

Muscles. — In addition to the degenerative changes which 
I have described as occurring in the internal organs in 
typhoid fever, I must say a word concerning those which 
so recently have been found almost invariably present 
in the voluntary muscles. This muscular degeneration 
is of two varieties : First, a granular degeneration, which 
corresponds to ordinary fatty degeneration. Second, a 
waxy degeneration, which consists in the conversion of the 



MOEBID ANATOMY. 13 

contractile substance of the primitive bundles into a homo- 
geneous, waxy shining mass. Often both forms of degen- 
eration occur together, sometimes one and sometimes the 
other predominating. 

In both forms of degeneration the muscular fibres become 
thicker and more brittle than normal. In the highest de- 
grees of degeneration the muscular fibres are entirely lost, 
and the muscle may present a yellowish or whitish appear- 
ance, so that hardly any traces of the normal color of the 
muscle remains. During convalescence the normal red 
color of the muscle returns. This muscular degeneration, 
however, is not peculiar to typhoid fever, but is met with 
in all severe infectious diseases. 

The want of muscular power, which is so prominent a 
symptom during the height of the fever, may depend on the 
disturbances of the nervous system, but the excessive loss 
of muscular power which is so often present during conva- 
lescence is due almost entirely to the muscular changes. 
The physical strength returns gradually during convales- 
cence as the muscles are regenerated, and it may be months 
before it is fully re-established. The muscles of the tongue 
undergo degeneration in the same way as the other vol- 
untary muscles, which accounts in some degree for the 
interference with the function of that organ so often a 
prominent phenomenon of the disease. 

The salivary glands enlarge, become firm and tense, and 
assume a more or less brown-yellow color. They have the 
consistency of cartilage. Late in the disease the hardness 
diminishes, and they assume a red color. These changes 
are due to a parenchymatous degeneration of the glands, 
which has been preceded by a cellular hyperplasia. It 
accounts to a certain extent for the diminution of the 
salivary secretion, causing a dryness of the patient' s mouth, 
which is so marked and constant an attendant of the fever. 

Similar cellular and parenchymatous changes take place 
in the pancreas. 

Changes similar to these occur in other febrile diseases, 
so that they cannot be regarded as characteristic of typhoid 
fever. 



LECTURE II. 



TYPHOID FEVER. 

Morbid Anatomy {continued). — Intestinal Lesions. — Eti- 
ology. 

At my last lecture I completed the history of those pa- 
renchymatous changes which are most frequently met with 
in typhoid fever. I mentioned that these changes could 
not be regarded as characteristic of this type of fever, for 
they are present in other diseases. By some these degen- 
erations are regarded as the necessary result of a pro- 
longed high temperature, but they are in no way different 
from those degenerations which occur as the result of 
blood-poisoning where prolonged high temperature does 
not occur. Especially is this the case in those diseases 
which are marked by their malignity rather than by their 
high temperature, as, for instance, acute yellow atrophy 
of the liver. 

Continuing the history of the morbid anatomy of this 
fever, I now come to those changes which occur in the 
lymphatic system of the intestinal track. 

The Intestinal Lesions. — These are the most impor- 
tant pathological lesions, and have been called the charac- 
teristic lesions of the disease, as these intestinal changes 
distinguish this fever from all other forms of acute disease. 

As the poison of small-pox manifests itself by certain 
changes m the tegumentary investment of the body, and 
the poison of epidemic cerebro- spinal meningitis by the 
formation of pus in the meshes of the pia mater, so the poi- 



MOKBID ANATOMY. 15 

son of typhoid fever acts directly upon the mucous mem- 
brane of the small intestine, giving rise to a catarrhal 
inflammation accompanied by changes in its anatomical 
structure, which, in the order of their development, are 
characteristic of the disease. The character and extent of 
these changes depend upon the duration of the fever and 
their nearness to the ileo-csecal valve; the changes are 
most marked in the patches nearest to the valve, and less 
marked in those farthest removed from the valve. 

In describing these intestinal lesions, I will suppose that 
w T e are examining a severe, well- developed case, which runs 
its regular course without complication. The changes can 
be most conveniently studied by first considering those 
which occur within the first week of the disease ; then, 
those which are developed within the second week ; next, 
those which are most commonly found in the third week ; 
and lastly those which occur within the fourth week. They 
appear to begin as a catarrhal inflammation of the mucous 
membrane. During the first weeJc the mucous membrane 
surrounding the glands, especially that surrounding the 
Peyerian patches, becomes hypersemic and swollen ; gradu- 
ally the glands become more and more elevated, their sur- 
face assumes a dark reddish color, interlaced by white 
lines; this is known as the "shaven-beard appearance" 
These changes begin and are most marked in the glands 
nearest the ileo-csecal valve ; they are generally well marked 
within forty-eight hours after the commencement of the 
disease, but are not fully developed until the end of the 
first week. By the end of the first week all the glands are 
involved which are likely to undergo change. 

In the second week, the mucous membrane of the intes- 
tine becomes less red ; the agminated and the solitary 
glands more elevated ; the white lines upon their surface 
disappear, and they assume a uniformly red color. An 
unusually rapid cell development takes place in the folli- 
cles. By this excessive development and the multiplication 
of the cell elements of this gland structure, the follicles 
become swollen in all directions. Usually the new cell 
growth extends beyond the limit of the follicles, so that the 



16 TYPHOID FEVER. 

adjoining mucous membrane is also infiltrated witli cells. 
These newly formed cells may wander through the muscu- 
lar coat and penetrate the sub-serous tissue. By the mid- 
dle or latter part of the second week the process passes 
into its second stage, and necrotic changes are established 
in the newly formed tissue. These morbid changes may 
terminate in two ways : first, the new elements in these 
ductless glands may become disintegrated and undergo 
absorption, and in this way they may gradually undergo 
resolution ; second, individual follicles of the agminated 
glands may rupture and discharge their contents into the 
intestine ; third, the most frequent and characteristic ter- 
mination of the typhoid process is the separation of the 
dead tissue as a slough, and the formation of the typhoid 
ulcer. Usually the sloughing and removal of the necrotic 
tissue does not take place until the third week of the 
disease. The surface of the ulcers now presents a yellow 
appearance, simply because they have been stained yellow 
by the bile. As the sloughs gradually loosen and fall off, 
there is a loss of substance which extends to the deeper 
layer of the mucous membrane, removing the entire gland 
and the mucous tissue surrounding it, laying bare the 
muscular coat of the intestine. The necrotic process may 
extend and involve the muscular tissue and end in perfora- 
tion of the peritoneal covering. 

The size and form of the ulceration corresponds to that 
of the necrotic tissue ; if an entire Peyerian patch is 
necrotic, an elliptical ulcer is formed, with its long axis 
corresponding to that of the intestine. In the jejunum and 
large intestines the ulcers are usually small and round. 
The edges of the ulcer are sharp, tumid, and overhang the 
floor of the ulcer. Sometimes the ulcers are hemorrhagic. 

In the fourth week the process of cicatrization is com- 
menced. Gradually the swollen edges of the ulcers sub- 
side, granulation-tissue springs up from their base, con- 
nective-tissue membrane is formed, the edges of the ulcers 
become united at their base, which is covered with a layer 
of epithelium. The gland structure is never regenerated. 
The cicatrix which is formed by the healing of these ulcers 



M0EBIB ANATOMY. 17 

is slightly depressed, and less vascular than the surround- 
ing mucous membrane. During the healing process the 
cicatrix becomes more or less pigmented ; these pigmented 
scars may be recognized years after the cicatrization has 
taken place. These cicatrices seldom cause any puckering 
or diminution in the calibre of the intestine. In many 
cases the process of cicatrization does not pursue this regu- 
lar course ; while one portion of the ulcer is cicatrizing, the 
process of ulceration in another part may be extending; 
such long-continued ulceration may prolong convalescence, 
and even cause death from exhaustion. 

I will now briefly review these intestinal changes, and if 
you will bear in mind the weekly order in which they 
occur, you will better remember them. 

The first thing noticed is congestion, which is most 
marked around the glands ; with this congestion the glands 
become changed in color. Next, the glands become en- 
larged, which enlargement is due to a rapid development of 
cells within their structure ; these cells are for the most 
part lymphoid ; but, in addition, there are present large, 
round cells, with several nuclei. These large, round cells 
are formed not only in the glands, but in the mucous and 
submucous tissue adjacent to them ; consequently, the 
enlargement encroaches more or less upon the surrounding 
mucous membrane. These newly formed cells not only 
swell the glands and press upon each other, but they press 
upon the capillary vessels which furnish these structures 
with nutrition ; consequently, there is an interference of 
the circulation of the gland structure, and as a result the 
glands become more or less anaemic ; degenerative changes 
occur as the result of impaired nutrition. 

In some of the enlarged glands the new elements become 
disintegrated and are absorbed, and the process ends in 
resolution ; in others, individual follicles soften, break 
down, and their contents are discharged into the intestinal 
canal, and the patches acquire a reticulated appearance. 
More frequently, a necrotic process is established which 
causes the removal of the entire gland and its contents, 
leaving an ulcer with everted and perhaps overhanging 
2 



18 TYPHOID FEVER. 

edges, with the muscular coat of the intestine for its base. 
It is now ready for the cicatrizing process, and if it pro- 
gresses regularly, first the edge of the ulcer becomes in- 
verted, then the base of the ulcer is covered with new connec- 
tive-tissue cells, the edges become adherent to it, new con- 
nective-tissue cells are thrown out upon the edges, and the 
formation of new tissue goes on increasing until finally the 
process of repair is complete. These ulcers do not always 
run such a regular course and terminate thus favorably. 
If the nutrition of the glands and the surrounding tissues is 
so interfered with that a gangrenous ulceration is estab- 
lished, sloughing follows, and the gland, with the muscular 
and other tissues in the neighborhood of the ulcers which 
are the seat of cellular infiltration, is removed. In some 
instances the necrotic process continues to extend and in- 
volves the peritoneum, causing perforation of the intestines 
and a fatal peritonitis. These ulcers may assume a hemor- 
rhagic character, with a surface of a dark color. Under 
these circumstances they are frequently the seat of profuse 
hemorrhages, which may destroy the life of the patient. 
Usually, when such accidents occur, vessels of considerable 
size are involved in the ulcerative process. Whenever the 
sloughing process is arrested, repair takes place in the man- 
ner already described. 

As I have stated, these ulcers may be developed in the 
jejunum, the ileum, the stomach, and the large intestines. 
In the lower part of the ileum, at the ileo-csecal valve, they 
are usually of large size — so large that only small portions 
of healthy mucous membrane are left between them ; in the 
jejunum, stomach, and large intestines they are usually 
round and of small size. 

Mesenteric G-lakds. — Associated with these intestinal 
changes, analogous changes take place in the mesenteric 
glands. These mesenteric changes are also most marked in 
the glands situated nearest the ileo-csecal valve ; they are 
secondary to the changes in the intestinal glands, and are 
usually affected in a degree corresponding to the extent of 
the intestinal lesions. The glands are first congested, then 
there is a production of lymphoid and large cells similar to 



MOEBID ANATOMY. 19 

those which are found in the enlarged intestinal follicles, 
the glands become enlarged, and are the seat of an acute 
cellular hyperplasia. When the enlargement has attained 
its full size, the hyperemia diminishes, and the cellular 
elements begin to disintegrate and are absorbed. In about 
one-half the cases the enlargement reaches its maximum 
size by the middle of the second or at the commencement 
of the third week. The enlarged glands vary in size from 
that of a hazelnut to a small hen's egg. In the stage of 
retrogression some of the glands simply shrink and return 
to their normal condition ; in other glands partial softening 
takes place and afterwards absorption, leaving a fibrous 
cicatrix. If the glands reach a very large size, absorption 
is incomplete, and dry, yellow, cheesy masses are left, in 
which after a time salts of lime are deposited and they be- 
come enclosed in a fibrous capsule. In rare instances the 
glands become fluid, their capsules are destroyed, and the 
softened masses escape into the peritoneal cavity and cause 
peritonitis. 

A calcareous condition of the mesenteric glands, like the 
pigmented cicatrices of the solitary and agminated glands, 
give evidence of a previous severe attack of typhoid fever. 
There is yet another pathological lesion of typhoid fever oc- 
curring during convalescence, concerning which I will speak 
— namely, a suppurative inflammation in the cellular tissue 
upon the surface of the body. The inflammation is not of 
an active type, but is accompanied by some redness and 
pain ; gradually a tumor is formed at the seat of the inflam- 
mation ; usually this occurs where there is the greatest 
amount of pressure. After a time fluctuation becomes dis- 
tinct, the swelling increases ; sometimes two or more of 
these swellings coalesce, and finally an immense abscess 
may be formed, which when opened will discharge a pint or 
more of pus. These abscesses are due to suppurative in- 
flammation in the cellular tissue of the skin. Retro-pha- 
ryngeal ulcers are the result of suppurative inflammation 
of the connective tissue. As a result of imperfect nutrition 
of the skin, a gangrenous inflammation of the skin may be 
developed, which gives rise to " bed-sores," as they are 



20 TYPHOID FEVEK. 

commonly called. These are especially liable to occur in 
the latter stages of a typhoid fever which has been attended 
by a prolonged high temperature. The slough may form 
over the trochanters, over the sacrum, or wherever the tis- 
sues have been subjected to pressure for a long time, and is a 
consequence of impaired nutrition of the skin. Sometimes 
this gangrenous process not only involves the skin, but also 
the subjacent cellular tissue and the muscles. Gangrene of 
the toes and portions of the integument which are not sub- 
jected to pressure is due either to thrombosis or embolism. 

This completes the history of the anatomical lesions of 
typhoid fever. In connection with this history I would call 
your attention to something of special importance, which I 
wish you would remember, namely, that typhoid fever is a 
specific disease ; that it has a specific pathological lesion, 
a catarrhal inflammation of the intestinal mucous mem- 
brane, attended by special follicular changes ; and though 
you may find present in other diseases changes closely re- 
sembling those which I have described as the characteristic 
lesion of typhoid fever, yet there is no other disease in 
which these changes have a regular development, in which 
the different stages can be indicated with a degree of cer- 
tainty by days and weeks. 

Etiology. — We very naturally pass from the considera- 
tion of the morbid anatomy of typhoid fever to its etiology. 
According to the classification of fevers which I have 
adopted, it is included in the list of miasmatic-contagious 
fevers. Usually, it has been regarded as an endemic form 
of disease. There seems to be no connection between its 
development and destitution ; for not only does it choose its 
victims from the hovels of the poor, but from the dwellings 
of the middle classes, and from the palaces of the rich. It 
may occur as an isolated case, or whole households and 
neighborhoods may be stricken down with the disease. We 
must therefore regard the causes of its production as local 
and limited, and not widespread. It is possible for it to 
prevail as an epidemic, but it must first have been endemic. 

In studying the etiology of this fever, two prominent 
questions present themselves : 



ETIOLOGY. 21 

First. — Is it a contagions form of disease? 

Second. — Is it ever of spontaneous origin ? 

The question of contagion is one that has been very 
thoroughly discussed. For many years representative med- 
ical men have differed upon this point. After years of 
careful investigation, I think it may be now unhesitatingly 
stated that facts do not sustain the opinion that typhoid fever 
is ever, strictly speaking, a contagious disease, or that it is 
ever directly transmitted from one individual to another. 

Persons sick with this fever are now admitted into our 
general hospitals, and are placed in beds by the side of 
patients sick with pneumonia or any form of chronic dis- 
ease, without endangering the lives of such patients. This 
fact shows how generally the profession regard this disease 
as non-contagious. Typhoid fever is no longer restricted 
by quarantine regulations. All these facts tend to dispose 
of the question, Is it a contagious disease % 

The question, Is typhoid fever of spontaneous origin % has 
also been thoroughly discussed, and there are strong advo- 
cates on both sides of the question. 

Some of those who believe that it may have a spontane- 
ous origin maintain that the poison which gives rise to it is 
developed by the decomposition of organic matter, and that 
the specific character of the fever is due to the particular 
substances which are undergoing decomposition. Others 
maintain that the decomposing substance is mainly human 
excrement — in other words, that decomposing human excre- 
ment is necessary for the production of the peculiar poison 
which gives rise to typhoid fever. Again, others who 
believe that the disease is of spontaneous origin maintain 
that the presence of vegetable matter in certain conditions 
is necessary for its production, and that these conditions 
are similar to those which exist when miasmatic fevers are 
developed, the difference in the two poisons depending 
rather upon the rate of temperature than upon the charac- 
ter of the ingredients. 

There is a view only recently advanced in regard to the 
origin of typhoid fever, that sewer gases contain the poison 
which has the power of developing the disease. 



22 TYPHOID FEVER. 

On the other hand, it is maintained by those who do not 
believe in the spontaneous origin of this fever that, in addi- 
tion to decomposing animal and vegetable matter, it is 
necessary that the specific typhoid poison shall be incor- 
porated in the decomposing mass. It is the leaven (if you 
choose so to call it) which is to leaven the whole mass. 
Daily observation seems to prove clearly that vegetable 
or animal decomposition alone is not sufficient for the 
development of this disease, even admitting that it depends 
upon the decomposition of human excrement. In how few 
of the many dwellings permeated with the effluvia from 
privies do the inmates have typhoid fever. 

Again, facts do not sustain the claim of those who say 
that sewer gases contain the typhoid poison, for those cities 
in which the sewerage is most imperfect, and those houses 
most frequently permeated with sewer gases, are not the 
hotbeds of typhoid fever. Again, this fever is more preva- 
lent in the country than in the city, in places where there are 
no sewer gases ; indeed, well-marked cases of typhoid fever 
are of quite rare occurrence in the city, and when they do 
occur seem to be developed independently of defective sew- 
erage. In other words, all the elements which favor its pro- 
duction may be present, such as animal and vegetable 
decomposition or sewer gases, and yet not a single case of 
typhoid fever be developed, until some person having 
typhoid fever comes within the precinct, or some substance 
containing the typhoid poison is brought within the boun- 
daries favorable to its development ; then a severe endemic 
of the disease may be developed. 

In carefully reviewing the history of the origin of this 
disease in the different localities in which for the first time 
it has suddenly appeared and prevailed, we will find that 
the advent of one suffering from the disease, or the intro- 
duction of matters from such a person, has been the start- 
ing-point of the endemic ; in other words, that one of these 
two conditions is a primary necessity for its production. 

We therefore almost necessarily reach the conclusion that 
something is necessary for the development of the typhoid 
poison besides favorable external conditions ; that animal 



ETIOLOGY. 23 

and vegetable decomposition does not primarily originate 
the poison, bnt furnishes a favorable soil for its growth 
and development. 

Facts warrant us in making the statement that while on 
the one hand typhoid fever cannot be regarded as a strictly 
contagious disease, on the other hand it is not of spontane- 
ous origin. 

It is hardly necessary for me to review all the facts which 
have a bearing upon this subject. I believe any unpreju- 
diced person will arrive at this conclusion from the careful 
study of them, that when typhoid fever makes its appear- 
ance in any locality, its development is preceded by the 
introduction of a specific typhoid poison, which has been 
reproduced (in most instances) in connection with decom- 
posing human excrement. 

The question now arises, What is the real nature of that 
poison derived from a person sick with typhoid fever, which 
has the power of indefinitely reproducing itself outside of 
the body in connection with decomposing organic matter, 
and thus becomes the infecting agent, when individuals are 
brought within its influence % 

The history of endemics of typhoid fever leads to the con- 
clusion that the poison is contained in the fsecal discharges 
of the sick. When such excrement is in a fresh condition 
the poison is not active ; it must go through a stage of 
development outside of the body. This may take place in 
the excrement itself, but it goes on more rapidly and abun- 
dantly if the excrement is collected in privies or in earth 
that is already saturated with organic matter. In this way 
you can readily explain how a typhoid fever patient com- 
ing into a locality previously free from the disease can 
establish there a focus of infection, from which many per- 
sons may become diseased. 

It is evident that this poison is not active in its fresh 
state, from the fact that the disease is not carried directly 
from one individual to another — as attendants, nurses, and 
physicians are no more liable to the disease than those who 
are in no way exposed to the disease and live in a healthy 
locality. Mothers may sleep in the same bed with children 



24 TYPHOID FEVEB. 

who are sick with the fever without contracting the disease. 
As has already been stated, in order that typhoid excrement 
shall become effective in the transmission of the poison, it is 
necessary that it should go through a stage of development in 
connection with organic matter outside of the body ; so it 
passes from the diseased individual to the localities which 
are favorable to its development, and again from these lo- 
calities into the human body. 

It is difficult to determine the period of incubation, or 
length of time the poison must remain in the body before 
symptoms of the disease are manifest. The history of iso- 
lated cases would lead to the conclusion that the period 
varies from fourteen to twenty days. 

The next question that arises is, How does the typhoid 
poison gain admission to the human body % Undoubtedly 
there are two principal sources of infection, namely, the air 
we breathe and the water we drink. A large number of 
well-authenticated histories have now established the fact, 
that this fever may be developed by gases which emanate 
from privies, sewers, etc., which have been the receptacle of 
excrement from typhoid patients, and also, by drinking 
water from springs and wells which have become contami- 
nated by matters from adjoining privies and cesspools. It is 
also now an accepted belief, or rather, is regarded as an 
established fact, that water remains contaminated, though 
far remote from the point where it came in contact with a 
defective sewer or water-closet. 

Soil pipes and sewerage may be defective for a long time, 
perhaps a year, or even longer, and no case of typhoid fever 
occur, when suddenly an endemic of typhoid fever breaks 
out, and careful investigation shows that its development 
was preceded by the introduction of the excrement of a 
single individual sick with the disease. 

It is the belief of some that milk can convey the typhoid 
poison, and there is evidence in favor of this opinion ; but I 
think there is stronger evidence that the water used to di- 
lute the milk, and not the milk itself, is the medium through 
which the poison is transmitted. 

This poison has great vitality. Typhoid fever frequently 



ETIOLOGY. 25 

occurs in the same locality year after year, when the 
surrounding conditions are favorable to its development. 
Those conditions which favor its development are more fre- 
quently present in the autumn than at any other season of the 
year, and for this reason it has been called Autumnal fever. 

Usually it makes its appearance in a locality, year after 
year, at about the same time ; case after case is developed 
until entire households and neighborhoods become its vic- 
tims. Individuals who come to care for the sick may con- 
tract the disease, and even persons who visit houses in which 
the disease is prevailing may afterwards develop the fever, 
contracting it, not from the sick, but from the infected at- 
mosphere of the locality. 

Age must be regarded as a predisposing cause of typhoid 
fever. It is much more likely to occur in young than in 
old persons ; it occurs most frequently between the ages of 
fifteen and twenty-five, and is rarely met with in persons 
over fifty. 

There are also individual idiosyncrasies which seem to 
predispose to this fever. Some contract it upon the slightest 
exposure to the influence of the poison, while others, fre- 
quently brought in contact with it through long endemics, 
escape. Again, an individual may have repeated attacks of 
typhoid fever. I have in mind a physician who had typhoid 
fever four times, the last attack proving fatal. A person 
who has had typhus or scarlet fever is not likely to have a 
second attack, but no such immunity follows an attack of 
typhoid fever. Whatever view w T e take of the exact nature 
of the typhoid poison, it has been quite conclusively de- 
monstrated that this poison differs very essentially from 
that of other fevers. 

From this brief review of the etiology of this fever, we are 
led to the following conclusions : 

First. — That its development is independent of over- 
crowding, and that it attacks the rich and poor indiscrimi- 
nately. 

Second. — That it may be communicated from one person 
to another through the excrements which have undergone 
decomposition after their discharge. 



26 TYPHOID FEVER. ' 

Third. — That an endemic of typhoid fever only occurs 
where the air or drinking water of the locality has become 
poisoned by emanations from typhoid excrements which 
have undergone decomposition, and that, if the fever be- 
comes epidemic, it is a circumscribed epidemic, and not 
widespread. 

Fourth. — That the exact nature of the typhoid-fever poi- 
son is still unknown. 



LECTURE III. 



TYPHOID FEVER. 

Symptoms. 

I shall this morning commence the history of the symp- 
toms of typhoid fever. 

If I should attempt to give you a correct picture of this 
disease — one perfect in all its colorings — it would occupy 
too much time, and you would become so confused as to 
be unable to recall even the outline of the picture. 

After I have briefly spoken of the manner in which this 
disease makes its advent, I shall consider the prominent 
symptoms of a typical case, and then discuss in detail these 
symptoms, without special regard to the time of their oc- 
currence. This fever is usually insidious in its approach, 
and comes on with a certain degree of uneasiness through- 
out the system ; the patient feels uncomfortable, has no 
pain, but feels that he is about to be sick. If the individual 
is in a region where the disease is prevailing, it is quite 
common to hear the expression, "I believe I am going to 
have the fever," and yet those who make such complaint 
will scarcely admit that they are sick. They complain of a 
grumbling headache, more or less aching of the limbs, "a 
tired feeling all over," chilly sensations, alternating with 
flashes of heat ; loss of appetite, and not unfrequently nau- 
sea and vomiting are present. These premonitory symp- 
toms gradually increasing in severity, by the fifth or sixth 
day the patient is compelled to take to his bed. At this 
early period there may be a slight diarrhoea. In very mild 
cases the disease comes on so insidiously, and with symp- 
toms so mild, that the patient is often able to pursue his 



28 TYPHOID FEVER. 

ordinary avocations, complaining only of an undefined in- 
disposition — not feeling exactly well, but not regarding 
himself as really sick. In very many severe cases it is im- 
possible for the patient to accurately fix upon the time 
when the fever commenced. In no case will you be able to 
make an early positive diagnosis. Typhoid fever may be 
suspected, but that is as far as you can safely go. 

In all cases variation in temperature is one of the most 
important early symptoms. Such variation in temperature 
in a typical case may be divided into four periods, of one 
week each, which correspond to the four weeks of the 
disease. 

In the first week there is a gradual and steady rise in 
temperature, with regular morning and evening variations. 

This is one of the characteristic features of the disease. 
If, in any case of fever, you find, while making your ther- 
mometrical observations, that there is a gradual rise in tem- 
perature, marked during the first week by regular morning 
and evening variations, you may be quite certain your 
patient has typhoid fever. This gradual rise of, and these 
variations in temperature are not present in every case, but 
when they are present they will greatly assist you in mak- 
ing an early diagnosis. 

It has been said that typhoid fever is the only disease, 
except double quotidian intermittent fever, that gives two 
full therm ometrical curves within twenty-fours ; that is, 
two full remissions and two exacerbations. If this is true, 
it helps to explain certain high temperatures in the morn- 
ing, and affords valuable assistance in making a diagnosis. 

During the second week the variations in temperature are 
slight, retaining, however, the same degree of exacerbation 
which was reached at the end of the first week. 

The variations during the third week are remittent in 
character. 

During the fourth week they become intermittent, and 
the range of temperature in the exacerbations is lower. 
The variations in pulse correspond to the variations in tem- 
perature. During the first week the pulse gradually be- 
comes more and more frequent, and remains at the height 



SYMPTOMS. 29 

reached at the end of the first week ; throughout the second 
and third weeks there are distinct morning and evening 
remissions ; during the fourth week it falls to its normal 
standard. 

On the seventh day, or sometimes between it and the 
twelfth day, the characteristic eruption appears. About 
this time the headache abates and more or less somnolence 
and delirium come on. The delirium at first is slight, and 
is only observed during the night. Day by day the patient 
loses fiesh and strength, and becomes more and more un- 
conscious, and all the phenomena of the typhoid state are 
developed, viz., a dry brown tongue, feeble pulse, low mut- 
tering delirium, stupor, tremors, subsultus, involuntary 
evacuations, and the other phenomena of great prostration. 

If the disease is to terminate favorably the amendment 
is usually gradual. The first sign of improvement is a de- 
cided remission of the fever. During the first week there 
is usually some diarrhoea ; in very many instances it is pres- 
ent before the patient seeks the advice of the physician. 
It may have ceased at the time he seeks such advice. 

Such, in brief, are the phenomena which attend the usher- 
ing-in and developing stage of an ordinary case of typhoid 
fever ; they are, however, subject to numerous modifica- 
tions. Some cases of this fever are mild throughout their 
entire course ; some are severe at first and mild afterwards ; 
some are mild at first and severe afterwards ; while others 
are severe throughout their entire course. 

In the detailed study of the prominent phenomena of 
this disease I shall not attempt to follow the order of their 
development, for they are subject to so many variations 
that such a course is impossible. 

In our attempt to analyze its principal symptoms I will 
first notice the changes which take place in the counte- 
nance. 

The Physiognomy. —As a rule, in the milder cases, the 
countenance has nothing peculiar in its appearance ; the 
patient does not even look ill. If the disease is of a severe 
type, by the second week the countenance assumes a char- 
acteristic appearance — there is a pale, olive, leaden look, 



30 TYPHOID FEVER. 

the eye becomes dull and the conjunctiva congested, and 
usually there is a small, rose-colored spot in the centre of 
the cheeks. The face does not assume the dark mahogany 
color, as seen in typhus, but in the advanced stage of the 
fever it has more of the hectic flush of phthisis. 

Tongue. — The tongue will also present certain changes. 
From the very outset it is covered with a light, white coat, 
but there is nothing special in its appearance before the 
end of the first week ; then it may become red upon its 
sides and tips, and show a slight disposition to dryness in 
its centre. As the disease passes into its second and third 
weeks, the tongue becomes more heavily coated, the coat- 
ing becomes brown and dry, and sordes collect upon the 
teeth and sides of the mouth in sufficient quantities to form 
crusts. These crusts may become thicker and more abun- 
dant as the disease progresses. At any period in the 
course of the disease the tongue may suddenly clear off, 
and present a shiny red appearance, "beef-colored," as it 
has been called. The tongue and lips may become dry, 
cracked, and fissured. As the sordes are removed from 
the lips, they will often bleed ; and in certain cases, more 
especially in the severer forms of the disease, the entire 
mouth and tongue may be covered with dark-colored in- 
crustations. Such incrustations are seen early in connec- 
tion with those cases where there are extensive blood- 
changes ; when present they are of grave significance. 

As soon as convalescence is established the changes in 
the appearance of the tongue are very marked. One of the 
first indications of convalescence is a moist condition of the 
tongue about its edges ; gradually its entire surface be- 
comes moist, and by the time convalescence is fully estab- 
lished it is restored to its natural condition. Gastric symp 
toms are always more or less prominent — loss of appetite is 
one of the earliest symptoms, and nausea and vomiting are 
quite common during the first week of the fever. The 
vomited matters usually consist of a greenish fluid. When 
vomiting comes on late in the fever, it is due either to sub- 
acute gastric catarrh, or it is symptomatic of local or geTF~ 
era! peritonitis. In a large proportion of cases the thirst is 



SYMPTOMS. 81 

excessive. The lips are parched, and in severe cases crack 
and bleed. In some cases hemorrhage from the gums 
occurs. 

Diarrhoea. — Although not invariably present, it is so 
frequent an attendant of this fever that it is considered one 
of its characteristic symptoms. It varies with the severity 
of the attack, the date of its commencement, and its dura- 
tion. The characteristic typhoid discharges are of a yel- 
lowish green color, described in the books under the term 
of "pea-soup discharges." Sometimes they are of a dark 
color, resembling coffee-grounds ; their reaction is alkaline. 
In some cases diarrhoea is present at the very outset of the 
disease, and continues throughout the entire course. In 
other cases it does not appear until the third week. The 
second week is the ordinary time for its appearance. When 
the diarrhoea appears late in the course of the disease, the 
discharges are more copious than when it appears early. A 
mild diarrhoea throughout the entire course of the fever is 
a favorable rather than an unfavorable symptom. In mild 
cases diarrhoea is sometimes absent. 

Intestinal Hemorrhage. — Intestinal hemorrhage is not 
an infrequent attendant upon typhoid fever. It occurs in 
about one in twenty cases, and varies in quantity from a 
mere trace of blood in the stools to a profuse discharge of 
from sixteen to eighteen ounces. The slight hemorrhages 
which sometimes occur early in the disease simply indicate 
a hemorrhagic tendency, the same as the epistaxis which is 
very frequently among the early symptoms. In both in- 
stances the bleeding comes from the capillaries of the 
mucous membrane. The more profuse hemorrhages are 
due to the opening of an artery in some intestinal ulcer. 
Hemorrhages due to this cause may be sudden and profuse, 
and may destroy the life of the patient. The usual time 
for the occurrence of these profuse intestinal hemorrhages 
is in the latter part of the second and during the third 
week. These hemorrhages are usually preceded by a sudden 
fall in temperature, perhaps two or three degrees ; if then 
in a patient severely ill of typhoid fever a sudden fall 
in temperature occurs during the second or third week, 



32 TYPHOID FEVER. 

accompanied by extreme prostration, it is very conclusive 
evidence that intestinal heinorrage lias occurred, although 
externally the hemorrhage may not have made its appear- 
ance. When intestinal hemorrhage occurs during the sec- 
ond or third week it must always be regarded as a grave 
symptom ; yet it is not necessarily followed by fatal results. 

The blood is usually fluid, rarely clotted ; generally it 
is of a bright red color, owing to the alkaline condition of 
the intestinal contents. Copious intestinal hemorrhages 
are more frequent in severe cases that have been attended 
by profuse diarrhoea. In one or two instances I have had 
patients die of intestinal hemorrhage before any blood 
had been voided externally. If the patient survive a pro- 
fuse intestinal hemorrhage, there is great danger of his 
dying from peritonitis. He may die unexpectedly by 
syncope a number of hours after a profuse intestinal hem- 
orrhage. 

Abdominal pain and tenderness are not usually present 
at the very outset of typhoid fever ; generally, and almost 
without exception in the severer cases, by the sixth day of 
the disease some pain and tenderness will be present in the 
right iliac fossa. The pain and tenderness usually increase 
as the disease progresses, and in the advanced stages it is 
sometimes so marked that slight pressure over this region 
gives the patient great pain. While examining this region 
in order to determine the presence or absence of pain and 
tenderness, remember never to press the surface with the 
ends of the fingers, but always make the examination with 
the palm of the hand; while making the pressure watch 
the face, and frequently you will be able to determine by 
the expression of countenance whether you are, or are not, 
causing pain, long before an audible complaint is made by 
the patient. 

It is also important for you to bear in mind the possible 
occurrence of a more severe abdominal pain — namely, that 
pain arising from intestinal perforation. The following are 
the characteristic symptoms of this lesion. If in the course' 
of a slight or severe form of this fever, or even when the 
disease has been latent and the diagnosis of typhoid fever 



SYMPTOMS. 33 

has not been clear, the patient should be suddenly seized 
with diarrhoea, pain in the abdomen, aggravated by pres- 
sure, perhaps at first localized in the right iliac fossa, but 
soon extending over the entire abdominal cavity, attended 
by symptoms of great prostration, a rapid, feeble pulse, a 
sunken, anxious expression of countenance, rapid tympani- 
tic extension of the abdomen, nausea and vomiting, quickly 
followed by coldness and blueness of the extremities, and 
the other signs of sudden collapse, you may be almost cer- 
tain that perforation of the intestines has occurred. I have 
known this accident to occur when convalescence was pro- 
gressing apparently safely and satisfactorily. Few live 
more than thirty- six hours after the occurrence of the per- 
foration. 

Tympanitis is another very common symptom of typhoid 
fever. Usually it is not present during the first week, but 
by the end of the first or the commencement of the second 
week a fullness of the abdomen will be noticed. As the 
fever advances, sometimes the distention often becomes ex- 
treme ; this is due to a collection of gas in the large intes- 
tine, developed from some change in the mucous membrane, 
the exact nature of which we do not fully understand. We 
only know that sometimes the mucous membrane of this 
intestine very rapidly secretes gas, or allows it to generate, 
and that the intestine becomes distended by its accumula- 
tion. When once it is developed it remains until convales- 
cence is fully established. It is always an important 
diagnostic sign of this fever. In connection with the devel- 
opment of the tympanitis, when firm pressure is made over 
the right iliac fossa, . a gurgling sound is produced ; but 
gurgling in the right iliac fossa cannot by any means be 
regarded as a positive symptom of typhoid fever, as it may 
occur in any disease where there is distention of the abdo- 
men due to accumulation of gas in the intestines. In ty- 
phoid fever, so long as the abdomen remains tympanitic, no 
matter what the temperature and pulse of the patient may 
be, he is in more or less danger, for it shows that there are 
intestinal changes still in progress, and that the reparative 
processes are not complete ; this is more especially the case 
3 



34 TYPHOID FEVER. 

when the tympanitis has continued from the active period 
of the disease into the period of convalescence. Therefore, 
the presence of tympanitis during convalescence is never to 
be lightly regarded. 

These are the most important symptoms which are refer- 
able to the alimentary tract, and may be regarded as form- 
ing, in connection with the temperature variations, the 
essential part of the history of this fever. 

Urine. — Extended and very careful analyses of the 
changes in the urine of typhoid fever patients have been 
frequently made, without giving any very practical results. 

Usually during the first two weeks of the fever the urine 
is diminished in quantity ; after the second week it is in- 
creased. During the time it is diminished in quantity, its 
color is dark and its specific gravity is high ; when it is in- 
creased and convalescence is established, it becomes pale, 
and its specific gravity is lowered. 

The amount of urea excreted daily throughout the active 
period of the fever is increased. The increase is in propor- 
tion to the intensity of the fever, subject in some degree to 
the quantity and quality of the food taken. It will be 
greater when large quantities of strong beef -tea are taken, 
than when the diet consists of milk. So long as the kid- 
neys are able to eliminate the excess of urea, no harm re- 
sults ; but if the quantity exceeds their power of elimina- 
tion, or if their function of elimination is interfered with, 
ursemic symptoms will be developed, such as delirium, 
stupor, and coma. 

Albumen in the urine is only of occasional occurrence in 
the course of typhoid fever. When present the quantity 
usually is small, and it is only temporarily present. It 
rarely appears before . the third week. Its appearance is 
often marked by the occurrence of cerebral symptoms. 
Renal epithelium and casts may or may not be present 
with the albumen. The spleen is often much enlarged, and 
can be felt through the abdominal wall. The enlargement 
is greatest in persons under thirty years of age, and during 
the second week of the fever. 

Nervous Phenomena. — The symptoms referable to the 



SYMPTOMS. 35 

nervous system are not so prominent in typhoid as in 
typhus fever; yet there are many cases in which these 
symptoms play an important part in its history. 

One of the most constant of this class of symptoms is head- 
ache. In the majority of cases it is one of the ushering-in 
symptoms of the disease. It is present in mild as well as iii 
severe cases ; sometimes it is confined to the forehead and 
temples, more often it extends over the whole head — not 
violent, but a dull, heavy pain. It usually increases in 
severity until the middle period of the disease, certainly 
until the close of the first week ; and generally associated 
with it there is intolerance of light and conjunctival injec- 
tion, pain in the back and limbs, and a general aching of 
the whole body. 

Somnolence is another nervous phenomenon present to a 
greater or less degree in all cases. In mild cases it does not 
appear until late, and usually is not long-continued. In 
the severer cases it appears early and continues until con- 
valescence begins ; in fatal cases it increases up to the time 
when the patient passes into a state of coma. It is often 
interrupted by delirium. 

In children this symptom is especially prominent, and is 
ver}^ valuable as a means of diagnosis. For example, if a 
child complains of feeling sick, without any well-defined 
pain, upon inquiry you find that he has had little or no 
sleep for two or three days ; gradually he passes into a state 
of somnolence, which at first is slight, but soon it becomes' 
profound ; you may infer that typhoid fever is about to 
be developed. 

Delirium is more frequently present than absent in ty- 
phoid fever. The character of the delirium varies ; the 
usual form is known as the *' low-muttering " delirium. 
This form is rather characteristic of this type of fever, and 
yet in very many cases the delirium may be violent in 
character, and may become maniacal to such an extent as 
to require physical restraint. JSTot unfrequently typhoid 
fever patients attempt to jump out of a window, or to in- 
jure themselves or their attendants in their endeavors to 
escape from fancied pursuers ; or they are seized with the 



36 TYPHOID FEVER. 

impression that their attendants are their personal enemies, 
or that within themselves there is something fearful that 
must be destroyed. 

It is very common for the minds of this class of patienta 
to be occupied with those things which engaged their atten- 
tion just prior to their illness. They imagine persons who 
are absent are about them, and not unfrequently call them 
in the most endearing tones, or denounce them with the 
most violent epithets. 

The delirium rarely comes on until the second week of 
the fever, and it commences and is most active at night. 
After it has once appeared it usually continues until con- 
valescence is established, and generally disappears during a 
sound sleep which attends the early stage of convalescence. 
The maniacal form of delirium in typhoid fever is usually 
most marked at night. During the low-muttering delirium, 
if the patient is asked questions, he will generally answer 
correctly. 

Muscular Prostration and Paralysis. — In all severe 
cases of typhoid fever muscular prostration is noticeable 
in the early stages, and increases with the progress of the 
fever. It is generally most marked during the third week. 
Where there is marked muscular paralysis, the urine and 
faeces are passed involuntarily, there is inability to protrude 
the tongue, and more or less difficulty in deglutition. These 
symptoms are often attended with difficulty or inability to 
articulate distinctly. Retention of the urine, occurring 
early on account of the inability of the bladder to evacuate 
itself, is a very unfavorable symptom ; the same is true of 
involuntary discharges from the bowels. 

Muscular Tremors. — Tremors of the hands, or tongue, 
or lips, are most often met with in young subjects, and^in 
those who are addicted to the use of spirits. Severe tremors, 
unaccompanied by much mental disturbance, often attend 
extensive intestinal changes. 

Spasmodic movements, such as subsultus, hiccough, etc., 
are observed in the advanced stage of severe cases. Eigid 
contraction of the muscles of the neck and those of the 
extremities are also sometimes present in severe cases. 



SYMPTOMS. 37 

General convulsions are of very rare occurrence, except 
in very young children, and when they occur have no spe- 
cial significance. 

Special Senses. — The symptoms referable to the special 
senses require little more than enumeration. 

As regards the sense of sight, there is nothing worthy of 
note, except that the eye assumes a dull expression and 
that the pupil is dilated ; some patients complain of hazi- 
ness of vision, which is increased when they assume a sitting 
posture. 

The sense of hearing is always more or less impaired ; 
this is most marked about the middle period of the fever ; 
then it is impossible for your patient to hear ordinary con- 
versation — you will be obliged almost to shout in his ear. 

Ringing and buzzing sounds in the ears are often com- 
plained of in the early stage of the fever. 

When the loss of hearing is confined to one ear, it is 
generally caused by ulceration of the mucous lining of the 
Eustachian tube, or by suppuration of the middle ear. 

The sense of taste usually is altered or perverted ; articles 
of food are tasteless, or have an unnatural flavor. When 
the tongue and mouth are covered with a heavy coating of 
sordes, with a tremulous tongue, the patient is unable to 
distinguish between bitter and sweet, and swallows the most 
disgusting doses without complaint. 

Hyperesthesia is another disturbance of a special sense. 
The surface of the body of a typhoid fever patient may 
become so sensitive that he will cry out with pain from the 
slightest touch. This hyperesthesia may be present during 
the first week, or may not be present until convalescence is 
established. It is most marked over the abdomen and lower 
extremities, and usually occurs in females of a hysterical 
tendency. It is of importance that you discriminate between 
cutaneous tenderness in the abdominal region, and the ten- 
derness of peritoneal inflammation. 

Epistaxis. — I have already referred to this symptom as 
of common occurrence in the early stage of typhoid fever. 
When it occurs during the first week, in most cases it is of 
little importance, except as a diagnostic sign of this type of 



38 TYPHOID FEVER. 

fever ; when it occurs during the third week, it becomes 
important as an element of prognosis, as it may be suffi- 
ciently profuse to destroy the life of the patient. Occurring 
late in the disease, unless it can be promptly arrested, it 
always jeopardizes the life of the patient. 

Emaciation is perhaps more marked and rapid in this 
than in any other form of fever. It commences early and 
is progressive. By the time a patient has reached the fourth 
week of a typhoid fever of even moderate severity, he is 
usually in a condition of extreme emaciation. In this par- 
ticular he markedly differs from a patient ill with typhus 
fever, for in the latter case emaciation to any great extent 
does not occur. 



LECTURE IV. 



TYPHOID FEYER. 

Symptoms {continued). — Differential Diagnosis. 

I will continue the history of typhoid fever, and de- 
scribe more in detail those variations in temperature which 
attend its development and mark its progress. As has al- 
ready been stated, the temperature at the commencement 
of a typical case of this fever is characterized by morning 
remissions and evening exacerbations ; and by these regular 
variations often you will be able to make a diagnosis dur- 
ing the first week of the disease. In order to estimate the 
real value of these variations, it will be found convenient to 
divide the fever into four periods which shall correspond to 
the four weeks of the disease. 

In making your therm ometrical observation, in this as 
well as in all other forms of fever, the thermometer may be 
placed in the axillse, the mouth, or the rectum. You must 
remember, however, that the temperature ranges about one 
degree higher in the mouth and rectum than in the axillae. 
I shall refer to axillary temperature whenever I speak of 
temperature without qualification. 

Usually the temperature begins to rise about noon on the 
first day of the development of the fever, and continues so 
to do until between six and eight o' clock in the evening, 
when it reaches its maximum height for that day ; then 
there is no change until midnight, when it begins to decline, 
and by six or eight o' clock in the morning it has reached 
its minimum decline, which is a degree higher than on the 
morning of the preceding day. After six or eight o' clock in 
the morning the temperature does not vary much until 



40 TYPHOID FEVER. 

noon ; then it again begins to rise, and by six o'clock in 
the evening it has reached its maximum elevation for that 
day, which is two degrees higher than on the evening of the 
preceding day. Again, at midnight it begins to fall, and by 
morning it has fallen a degree, which leaves the maximum 
temperature for the day a degree higher than on the preced- 
ing day. Thus it rises a degree each day, with regular 
morning and evening variations, until the eighth day of the 
fever, when, in most cases, it has reached its maximum 
height. During the second week the temperature remains 
at about the same maximum degree which it has reached by 
the end of the first week. There are morning and evening 
variations of a degree or more, but the maximum of the 
evening exacerbation remains the same. 

During the third week the remission becomes more and 
more marked, and with it the temperature falls, while dur- 
ing the exacerbation the temperature retains the same stand- 
ard as during the second week. By the end of the third 
week the morning temperature during the remission will 
have fallen two or three degrees below the point which it 
had reached during the second week. 

By the time the fourth week is reached, or at least by the 
middle of the week, the temperature becomes intermittent, 
and with each exacerbation it falls lower and lower, until 
by the end of the week the normal standard of temperature 
has been reached — it may fall a little below the normal 
standard. 

These are called the typical therm ometrical variations of 
typhoid fever, yet they are not always present ; besides, 
there are many things which will materially modify them. 
For instance, marked deviations from the record may be 
produced by complications which would never have been 
discovered but for the irregular thermometrical variations. 
By treatment, for a time the temperature can be very much 
lowered ; but, if the treatment be discontinued, it will again 
rise. In some cases you will be unable to ascertain the 
cause of the irregularity. 

Pulse.— The pulse is also subject to variations, which 
correspond very nearly with the variations in temperature, 



SYMPTOMS. 41 

and occur not only on different days, but at different hours 
on the same day. During the first week the pulse becomes 
more and more frequent, during the second and third weeks 
it remains at its height, and during the fourth week sinks 
to its normal average. During the whole course of the dis- 
ease it is less frequent in the morning than in the evening. 

If, at the commencement of the fever, the pulse is ninety- 
eight, it gradually increases in frequency, until, by the end 
of the first week, it has reached one hundred, or one hun- 
dred and ten per minute ; during the second week it remains 
at about this height ; after that time it may run as high as 
one hundred and twenty or one hundred and forty. Dur- 
ing the first and second weeks the rate of the pulse and the 
temperature range correspond, but after this time the par- 
allelism ceases, the failure of heart-power beginning to 
manifest itself. This failure of heart-power is indicated by 
an increase in the frequency and feebleness of the pulse, 
which at this time may reach one hundred and forty per 
minute, and yet the temperature show no alarming varia- 
tion. A pulse which remains for Hve or six consecutive 
days above one hundred and twenty per minute is a bad 
omen, for it shows extensive changes in the muscular tissue 
of the heart. Under these circumstances, the pulse may 
become irregular and intermitting. Should these irregu- 
larities and intermissions occur during the third week, in 
most cases they are followed by death. With an irregular 
and intermitting pulse, usually, you will find the first sound 
of the heart inaudible over the precordial space, and this 
indicates that prompt and judicious means must be em- 
ployed to restore, if possible, the heart's normal action, 
and thus relieve your patient and avert a fatal issue. 

The severity of the fever during the first and second 
weeks of its development is, to a great extent, determined 
by the frequency of the pulse and the height of the tem- 
perature. Although delirium and extensive tympanitis are 
important symptoms, yet they do not determine the result ; 
but if your patient, during the first, or at the commence- 
ment of the second week of the disease, has a pulse of one 
hundred and twenty per minute, and a temperature of one 



42 TYPHOID FEVEE. 

hundred and six, it is very doubtful whether convalescence 
can ever be established. 

You must remember that from feeble heart-power alone 
the pulse may increase in frequency, while the temperature 
is steadily falling. On the other hand, the pulse sometimes 
falls almost to a normal standard, while the temperature re- 
mains high. In either case, if these changes occur during 
the second or third week of the fever, they must be re- 
garded with suspicion. 

Eruption. — We now come to the study of what is known 
as the " characteristic symptom " of typhoid fever, namely, 
the eruption. Some have claimed that the eruption should 
be considered as a lesion of the disease, but I prefer to class 
it among the symptoms. It makes its appearance between 
the sixth and twelfth days, dating from the commencement 
of the fever (not from the day the patient takes his bed, but 
from the time the first symptoms of the disease manifest 
themselves), and it is not attended by any unusual sensa- 
tion. 

It remains visible from eight to fourteen days, leaving no 
stain or mark on the surface after its disappearance. It 
consists of isolated, lenticular spots scattered more or less 
abundantly over the surface of any part of the body, yet 
usually most abundant upon the chest and abdomen. There 
may be only a few spots visible at a time, or it m&y be so 
profuse as to cover the body like a rash. Two or three 
well-defined spots of the eruption are sufficient to establish 
the existence of the fever. Each spot is circular in shape, 
and varies in diameter from a point to a line and a half, 
rarely reaching two lines. It is slightly elevated above the 
surface of the surrounding cuticle, is of a bright rose color, 
disappears upon slight pressure, and returns as soon as the 
pressure is removed. Each spot remains visible for three 
days, and then disappears. Sometimes, as one crop of the 
eruption disappears another is developed, and this may go 
on for eight, twelve, or fourteen days. There are many 
cases in which only one crop appears. As soon as one spot 
makes its appearance, it is well to mark it with tincture of 
iodine or nitrate of silver, so that you may be certain that 



SYMPTOMS. 43 

your observations are always made upon the one point. If 
it is a spot of typhoid eruption, and one crop of eruption is 
to follow another, it will disappear within three days from 
the time at which it was first seen, and other spots will take 
its place. It is this feature which distinguishes the typhoid 
eruption from that of all other fevers. 

The question may be asked, Is this eruption essential to 
the diagnosis of typhoid fever? Doubtless there is no 
question in connection with its history which has given 
rise to more discussion than this. As a matter of course, 
this question has two sides. Many observers mention that 
the eruption is not constant, and consequently not neces- 
sary for its diagnosis ; while others, equally competent, 
maintain that, unless the eruption be present at some 
period during the progress of the disease, the diagnosis of 
typhoid fever cannot be made with positiveness. Jenner 
states that he found the eruption present in one hundred 
and forty-eight out of one hundred and fifty- two cases. I 
would not say that it is possible for typhoid fever to occur 
without the eruption, neither would I affirm that scarlet 
fever ever exists without the characteristic rash of the dis- 
ease ; but I do say that, as regards these respective fevers, 
that if no eruption was present, I would make the diagnosis 
with equal hesitancy in the one case as in the other. 

The eruption is usually most marked in cases of typhoid 
fever which occur between the ages of ten and thirty. Be- 
fore ten and after thirty years it is usually not as well 
marked, and may be readily overlooked unless careful 
search is made. 

I have described to you the prominent symptoms which 
are present during the course of a typical case of typhoid 
fever, and believe you will now be able to recognize the 
disease and to manage intelligently your typhoid fever 
patients. 

At this point let me state to you that the typhoid poison, 
in its operation on the human body, does not always effect 
the series of changes and symptoms which I have been 
describing. On the contrary, there are cases which run so 
mild a course that they can scarcely be dignified by the 



44 TYPHOID FEVER. 

name of fever ; besides, there are imperfectly developed 
cases which show a great diversity in their course, but they 
all can be included under two heads : 

First. — Mild typhoid fever, in which the symptoms are 
all mild. 

Second. — Abortive typhoid fever, in which the duration 
of the disease is markedly shortened. 

In the mild type, the fever runs its regular course, but 
it is of low grade. The temperature rises regularly until 
its maximum is reached, which rarely exceeds 103° F. ; 
then it remains stationary for a time, generally about a 
week ; then a decline follows in the same manner as was 
noticed in the typical case. This is the regular course of 
these cases if left to themselves, and, as a rule, they should 
be left to themselves. Some of these cases are so mild that 
the patients are not confined to the bed, nor even to their 
rooms, and perhaps throughout the entire course of the 
disease are able to transact a certain amount of business. 
Such cases have been called "walking cases" of typhoid 
fever. 

The eruption appears in these cases early, is of short 
duration, only a few spots appear ; usually there is only 
one crop. Diarrhoea is also present in most cases of this 
class, but it is of a mild type, the discharges from the 
bowels apparently giving relief to the patient. In some 
cases the diarrhoea alternates with constipation, or consti- 
pation may be present throughout the entire course of the 
disease, and the cases go on exhibiting a varying amount of 
fever for from twenty to thirty days, until gradually conva- 
lescence is established. This class of cases, if properly 
managed, rarely prove fatal ; but, if improperly managed, 
there is great danger. For instance, if a patient walks 
about while he is suffering from one of these so-called mild 
attacks of typhoid fever, he does it at great risk to life — in 
other words, there should be no "walking cases" of ty- 
phoid fever. A patient sick with typhoid fever, however 
mild the type, should take to his bed and remain there 
until convalescence is fully established, as it is impossible 
to say just how extensive the changes may be that have 



DIFFERENTIAL DIAGNOSIS. 45 

occurred in the intestinal track, and in the mildest type of 
the disease they may be of such a nature that very little 
physical exertion will cause intestinal perforation, which 
will be followed by a fatal peritonitis. 

The abortive form of typhoid fever is ushered in with all 
the symptoms of a typical case — headache, lassitude, pain 
in the limbs, nausea, etc. — and the temperature during the 
first week follows the regular variations of the fever. At 
the onset the disease has every appearance of a severe form 
of typhoid fever ; the temperature may rise as high as 
105° F. or 106° F. by the end of the first week ; delirium is 
often active, and diarrhoea is present. By the end of the 
second week, certainly by its close, if recovery occurs, the 
fever is cut short, and abruptly disappears ; the temperature 
falls to the normal standard, and the patient passes on to a 
state of rapid and complete convalescence. The eruption, 
diarrhoea, and all the urgent symptoms of the disease may 
be present, and yet before the end of the second week the 
patient may have fully convalesced. That it is the typhoid 
poison which thus acts upon the system, and gives rise 
to the characteristic symptoms of typhoid fever in these 
abortive cases, is evidenced by the fact that at the post- 
mortem examinations the characteristic typhoid intestinal 
lesions are found, and these, taken in connection with 
the presence during life of the typhoid eruption, estab- 
lish the diagnosis beyond question. There can be no 
doubt but that an individual may be affected, over- 
whelmed, as it were, by typhoid poison, and yet not de- 
velop well-marked typhoid fever. So, if only a moderate 
amount of typhoid poison is introduced into the system, a 
mild or an abortive type of fever will be developed. The 
natural powers of the individual to resist the action of 
such poisons must always be regarded, and should be 
taken into consideration in the treatment of a case. 

Differential Diagnosis. — In a typical case, after the 
fever is fully developed, the diagnosis is not difficult. The 
presence of febrile excitement, marked by evening exacerba- 
tions and morning remissions, headache, diarrhoea, abdomi- 
nal tenderness, and other abdominal symptoms, and the 



46 TYPHOID FEVER. 

presence of the characteristic rose-colored spots, are suf- 
ficient for a diagnosis. 

In the mild type of the disease, or when the symptoms 
are developed irregularly, or during the first week of a 
typical case, the diagnosis is often difficult, and sometimes 
impossible. The principal diseases which are liable to be 
confounded with typhoid fever are typhus and relapsing 
fevers, typho-malarial fever, acute tuberculosis, p}^8emia, 
septicaemia, pneumonia, and gastro-enteritis. 

The points of differential diagnosis between typhoid and 
typhus, relapsing and typho-malarial fevers, will be more 
apparent, and more readily comprehended, after we have 
studied these different forms of fever. I shall therefore not 
call your attention to their differential diagnosis until I 
have given you a history of these fevers. 

Acute Tuberculosis. — This disease is attended by very 
many of the symptoms which are present in, and by some 
supposed to be characteristic of typhoid fever. The fever 
of acute tuberculosis is of a remittent type, attended by 
evening exacerbations and morning remissions, delirium, 
a dry, brown tongue, a tendency to stupor, great prostra- 
tion, rapid emaciation, and sometimes by a diarrhoea, with 
abdominal tenderness and tympanitis. All of these are 
among the prominent symptoms of typhoid fever ; conse- 
quently these two diseases are frequently mistaken the one 
for the other. More than once have patients in Bellevue 
Hospital, with the diagnosis of typhoid fever, presented at 
the post-mortem examination the characteristic lesions of 
acute tuberculosis. If, therefore, patients with acute tu- 
berculosis may go through a large general hospital, under 
the observation of diagnosticians, who certainly are not 
men of inferior ability, and be supposed to have typhoid 
fever, there evidently is great danger of a mistake in diag- 
nosis. 

The higher range of temperature in acute tuberculosis 
than in typhoid fever is one of the distinguishing character- 
istics of the disease. Usually, early in the progress of the 
disease, it reaches 106° F. or 107° F., while in typhoid fever 
the temperature rarely reaches 106° F., and even then in 



DIFFEEENTIAL DIAGNOSIS . 47 

most cases not before the end of the second week of the 
fever, by which time you will have been able to deter- 
mine the true nature of the disease. Again, you will 
notice that there is no eruption, neither is there enlarge- 
ment of the spleen in acute tuberculosis, while both are 
very constant attendants of typhoid fever ; yet their 
absence is not positive proof that typhoid fever does not 
exist. 

In all doubtful cases you must take into account the 
family history of the patient, his immediate surroundings, 
whether typhoid fever is prevailing at the time, and whether 
the patient has been exposed to typhoid poison. These 
are important points, and by a careful study of them, if 
you are able to watch the case throughout its entire course, 
probably you will arrive at a correct diagnosis before the 
end is reached. Should you see the case during the first 
week of the disease, rely upon the presence of the rose- 
colored spots for a diagnosis of typhoid fever, and you will 
rarely mistake it for acute tuberculosis. 

Pyaemia and Septicaemia. — These diseases, while devel- 
oping, present many symptoms which resemble those of 
the developing stage of typhoid fever. In most cases you 
will be able readily to recognize them, as the surface of the 
body has a jaundiced hue ; there are no lenticular spots, 
and the febrile symptoms are irregular in their develoj> 
ment. There are exacerbations and remissions, but their 
appearance and disappearance are not marked by any reg- 
ularity, and usually there is more than one exacerbation 
and remission in the twenty-four hours. ]N"ot only are the 
variations in temperature irregular, but the temperature 
reaches a high degree much sooner, and ranges higher 
throughout its entire course in pyaemia and septicaemia 
than in typhoid fever. In pyaemia and septicaemia you 
will also have early in the disease profuse sweatings, great 
prostration, rapid emaciation, delirium, subsultus, tympani- 
tis, and diarrhoea, while in typhoid fever these do not come 
on until late in the disease. Besides, the history which 
precedes and attends the development of pyaemia and sep- 
ticaemia widely differs from that of typhoid fever. 




48 TYPHOID FEVER. 

There is a condition of septic poisoning occasionally met 
with, resulting from the introduction into the system of 
septic malaria through the drinking water, which so closely 
resembles that which is the result of typhoid poisoning 
that it is almost impossible to make a differential diagnosis. 
In these cases the absence of the rose-colored spots is almost 
the only distinguishing feature. 

Pneumonia. — Pneumonia, with typhoid symptoms, is 
sometimes mistaken for typhoid fever. It is called in your 
' books typhoid pneumonia. The differential diagnosis is not 
difficult if you remember that the pneumonia which com- 
plicates typhoid fever does not come on until late in the 
fever, and you have the regular history of typhoid fever 
preceding its development. On the other hand, when the 
typhoid symptoms are present from the beginning of, or 
come on at the end of the second stage of the pneumonia, 
the physical signs of the pneumonia will attend or precede 
the typhoid symptoms. There will be cough and the char- 
acteristic pneumonic expectoration ; there will be no erup- 
tion, and no typical variation in temperature. 

If you do not see a patient who is over sixtj^ years of 
age with this type of pneumonia until the second or third 
week of its progress, although evidences of lung consolida- 
tion may be present frequently, it will be very difficult to 
decide whether the pneumonia is or is not complicating 
a typhoid fever, and under these circumstances of course 
the differential diagnosis will be very difficult. 

GrASTRO-ENTERiTis. — In the adult this disease is quite 
readily distinguished from typhoid fever, as the diarrhoea 
and vomiting precede the febrile movement ; the fever is ir- 
regular in its development and progress, and the tempera- 
ture rarely rises higher than 103° F. In a child between 
two and six years of age it is very difficult to distinguish 
gastro-enteritis, or intestinal catarrh, as it is sometimes 
called, from typhoid fever. The eruption is not so promi- 
nent or constant a symptom in the child as in the adult, 
and with both diseases we have diarrhoea, tympanitis, and 
typhoid symptoms. These circumstances render many 
cases of this character difficult of diagnosis. When all 






DIFFERENTIAL DIAGNOSIS. 49 

the symptoms precede the fever, and you can have a his- 
tory of the case, and a thermometrical record from the be- 
ginning of the fever, in most cases you can readily make 
the diagnosis ; but if you do not see the case until it has 
reached the second week of its progress, and you have no 
accurate or reliable history of its development, a positive 
diagnosis is impossible. 

Trichinous Disease. — Poisoning by trichinae has fre- 
quently been mistaken for typhoid fever. This condition is 
not unfrequently attended by diarrhoea, vomiting, and the 
development of other typhoid symptoms ; but with poison- 
ing by trichinae there is almost constantly present muscular 
pains and oedema of the eyelids, which will be sufficient to 
arrest your attention. We have, then, in poisoning by 
trichinae, diarrhoea, vomiting, tympanitis, rapid emaciation, 
great exhaustion, a brown, dry tongue, high temperature, 
and other typhoid symptoms ; with these you have the 
oedema of the face, especially of the eyelids, and the most 
intense muscular pains. By removing a small portion of 
the muscular tissue and placing it under the microscope, 
the trichinae can be seen, and thus you will be enabled to 
make a positive diagnosis. 
4 






LECTURE V. 



TYPHOID FEVEK. 

Prognosis. — Duration. — Belapses. 

I have already spoken to. you of the differential diagnosis 
of typhoid fever, and will now give you some of the more 
prominent rales which should govern you in its prognosis. 

Prognosis. — Death may occur at any stage of this fever. 
A typhoid patient is not out of danger until all tympanitis, 
diarrhoea, and other abdominal symptoms which indicate 
that intestinal changes are still progressing, have disap- 
peared. Independent of complications the duration, type, 
and intensity of the febrile excitement has more to do than 
all the other elements in determining the prognosis in any 
case of typhoid fever. The height of the temperature on the 
eighth day determines the range of temperature that may 
be expected on each succeeding day. If upon that day it 
is not higher than 104° F. or 105° F., and has been regular 
in its development (independent of complications), the prog- 
nosis is good ; in uncomplicated cases it very rarely rises 
higher than the degree it has reached at that time. A pro- 
longed high temperature (above 105° F. ) after the first week 
renders the prognosis unfavorable. 

In mild cases, during the second week, a marked morning 
remission occurs, which begins early and continues until 
midday ; the evening exacerbation is late, and by the end 
of the second week there is a marked and permanent fall in 
the temperature. In severe cases, the opposite conditions 
are observed. A sudden rise in temperature, or a rapid and 
extreme fall at any period of the fever, is a very bad omen ; 




PROGNOSIS. 51 

the latter often precedes the occurrence of a severe intestinal 
hemorrhage. Marked variation from the typical tempera- 
ture of the disease indicates the existence of complications. 
Slight decline, accompanied by great fluctuation of tempera- 
ture, during the third week, is an unfavorable symptom. 
The natural power of an individual to resist disease, especi- 
ally the effects of prolonged high temperature, is a very 
important element in prognosis. The organ which is the 
surest indicator of such power (especially in typhoid fever) 
is the heart. If the pulse is full and regular, perhaps beat- 
ing at the rate of 110 or 115 per minute, if the cardiac im- 
pulse is good, and a distinct first sound can be heard, even 
though at the end of the second week the temperature 
stands as high as 106° F., the prognosis is favorable. If, 
however, the pulse has risen to 120 or 130 per minute, if the 
apex-beat is feeble or imperceptible, and the first sound of 
the heart is indistinct or altogether obscured, with a ten- 
dency to cyanosis and pulmonary oedema, the indications 
are that the patient's powers of resistance are failing, and 
under such circumstances the prognosis must be unfavor- 
able. It is not so much the rapidity as the regularity, a 
sudden falling and a sudden rising of the pulse, that indi- 
cates the impending danger. The rapid rising of the pulse 
upon the slightest excitement is the most unfavorable indi- 
cation, as it shows extensive heart-failure and a rapid giving 
way of vital power. 

A sudden fall of the pulse from any cause must always 
be regarded as an unfavorable indication. The abundance 
or color of the eruption does not influence the prognosis. 
Excessive tympanitis and severe abdominal pains are un- 
favorable symptoms. 

Severe and protracted muscular tremors, with subsultus, 
indicate danger. Sudden collapse during the second and 
third weeks of the fever is always attended with danger, as 
it is very likely to be due to copious intestinal hemorrhages 
or intestinal perforation. It sometimes occurs indepen- 
dently of either of these causes, but nevertheless is very apt 
to be soon followed by a fatal result. 

The prognosis is always bad in persons who are very fat, 






52 TYPHOID FEVER. 

and in those who are the subjects of gout, diseases of the 
kidney, or any other severe form of chronic disease. In all 
such persons, during the second and third weeks of the dis- 
ease, you must constantly be on the watch for the occur- 
rence of sudden collapse. 

Different opinions have been given as to the importance 
of intestinal hemorrhage in reference to prognosis. Some 
have regarded slight intestinal hemorrhages as beneficial, 
while others have regarded them as always of dangerous 
significance. 

My own experience leads me to the belief that when the 
hemorrhage is scanty it has little influence on the final re- 
sult. When it occurs before the twelfth day of the fever, 
it often does good by relieving the intestinal congestion. 
But when profuse, or even a slight hemorrhage after the 
twelfth day, is an unfavorable symptom and renders the 
prognosis unfavorable. The occurrence of the hemorrhage 
renders it probable that ulceration has extended to the ves- 
sels beneath the transverse muscular fibres of the intestine, 
and such ulceration is very apt to go on to perforation and 
a fatal peritonitis. So that although the patient may sur- 
vive the hemorrhage, there is great danger of death from 
peritonitis, and this danger must always enter into your 
prognosis, whether the hemorrhage is slight or severe. 

The influence of age is very great in determining the prog- 
nosis in any case of typhoid fever. 

The prognosis is much better in children than in adults. 
Occurring in persons over forty years of age, the prognosis 
is decidedly unfavorable, even though the symptoms may 
not indicate a severe type of the disease. 

In the case of those individuals who habitually use 
alcoholic stimulants, whose power of resistance to high 
temperature is diminished, the rate of mortality is very 
great. 

The puerperal state renders your prognosis especially 
unfavorable. The danger to the patient is equally great, 
whether the fever comes on prior to delivery or during 
puerperal convalescence. 

In this fever there is greater danger to those who are suf- 



PROGNOSIS. 53 

fering from any form of chronic disease than to those who 
are in a healthy condition at the time of the attack. 

Without delaying yon longer with those conditions in 
the ordinary course of the disease which influence its prog- 
nosis — the most important of which have been referred to 
under the head of symptoms — I will pass to the considera- 
tion of the complications which influence its prognosis. 
They are more numerous than those in any other disease. 

I will first briefly allude to those which are intimately 
connected with, or dependent upon, the morbid changes 
ordinarily incident to the disease, and afterwards speak of 
those which may be designated as accidental complications. 

The parenchymatous changes which take place in the 
different organs of the body, during the progress of this 
fever, necessarily influence prognosis. For instance, the 
muscular degenerations of the cardiac walls and the conse- 
quent loss of heart-power, which favors pulmonary and 
other lrypostatic congestions, and the diminished quantity 
of blood sent to the various tissues of the body, interfere 
more or less with their nutrition. Necrotic and gangrenous 
processes, sometimes met with in the cellular tissues of the 
surface and along the line of the intestines, also the venous 
thrombi which so frequently develop in a protracted case 
of this fever, are, to a certain extent, the result of this car- 
diac weakness. It is apparent that the development of ex- 
tensive cardiac degenerations must render the prognosis 
unfavorable. 

Excessive cardiac weakness favors the development of 
blood-clots in the heart-cavities ; these may break up and 
cause embolism somewhere in the course of the general cir- 
culation, and thus lead to changes which may destroy life. 
Again, intestinal perforations, one of the results of the in- 
testinal changes incident to the fever, render the prognosis 
most unfavorable. The same is true of copious intestinal 
hemorrhages coming on after the third week of the fever, 
as well as of all those glandular changes which are a part of 
the natural history of the fever, and which I have already 
described. 

Any of these changes may lead to complications which 



54 TYPHOID FEVER. 

endanger the life of the patient, and consequently, when 
they occur, necessitate a guarded, if not an unfavorable 
prognosis. 

Some of the prominent accidental complications which 
may occur in the course of typhoid fever, but which do not 
belong to its regular history, have their seat in the respira- 
tory organs. Slight bronchial catarrh is present in nearly 
every case, and can hardly be regarded as a complication. 
It is so much a part of the clinical history of the disease, 
that some have named this fever bronchial typhus. There 
is another much more serious bronchial complication, 
namely, catarrh of the smaller bronchi, or capillary bron- 
chitis. This usually comes on during the second or third 
week of the disease, and if extensive, greatly endangers the 
life of the patient. If, then, during this period of the fever, 
you have subcrepitant rales suddenly developed over the 
whole of both lungs, accompanied by great dyspnoea and 
an abundant expectoration of stringy mucus, you are war- 
ranted in giving an unfavorable prognosis. 

Extensive oedema of the lungs occurring with, or inde- 
pendent of, capillary bronchitis and pulmonary congestion, 
sometimes comes on suddenly during the third week of 
typhoid fever, and indicates great failure of heart-power. 
The slightest indication of its occurrence should always be 
regarded with suspicion. It is not unfrequently accom- 
panied by more or less extensive hemorrhagic infarctions 
of the lungs ; these depend on embolism of some of the 
branches of the pulmonary artery due to fragments of clots 
which have formed in the right side of the heart, the result 
of the cardiac weakness ; these often lead to gangrene of 
the lung. It is sometimes impossible to diagnosticate their 
existence during life. 

Pneumonia, when it complicates typhoid fever, is gener- 
ally latent. It comes on very insidiously, and unless you 
are on the watch for its development, and make frequent 
and careful physical examination, it will pass unrecognized. 
It is more frequently developed during the third and fourth 
week of the fever, and usually is catarrhal rather than 
croupous in character. At first only single lobules are in- 



PROGNOSIS. 55 

volved, but after a time an entire lobe becomes consoli- 
dated. When irregular variations in temperature occur 
during convalescence, or during the third or fourth week of 
the fever, there is reason to suspect the development of 
pneumonia. In the majority of cases the characteristic 
pneumonic cough and expectoration are absent. When- 
ever an extensive pneumonia complicates typhoid fever, the 
prognosis is especially unfavorable. 

Pleurisy does not occur so frequently, as a complication 
of typhoid fever, as does pneumonia or bronchitis. When 
it does occur, the almost invariable product of the inflam- 
matory process is pus. Usually it comes on late in the dis- 
ease, comes on insidiously, and is quite likely to pass un- 
recognized unless frequent physical examinations of the 
chest are made. In many instances it is really a sequela of 
the fever, not developing until three or four weeks after the 
fever has run its course. Its occurrence must always be re- 
garded as unfavorable, for a year or even longer time must 
elapse before recovery can take place, and even then recov- 
ery is doubtful. 

Occasionally laryngitis is a serious complication of this 
fever. It generally occurs in those cases where the fever 
has been very protracted, and there is great prostration. 
Its presence is marked by sudden and very intense inflam- 
mation of the mucous membrane of the glottis, which is lia- 
ble to become cedematous, when death may suddenly occur. 
It may lead to ulceration of the mucous membrane. When- 
ever, during any stage of a typhoid fever, the characteristic 
symptoms of laryngeal obstruction occur, remember the 
danger of oedema glottidis and of extensive laryngeal ul- 
ceration, and promptly resort to those means which shall 
relieve the unpleasant symptoms, and avert the danger 
which threatens your patient. 

Pyaemia may be met with as a complication during con- 
valescence from typhoid fever, but it is not of as frequent 
occurrence as septicaemia. Whenever we have septic poi- 
soning developed, with extensive sloughs in the intestines, 
the prognosis is exceedingly unfavorable. 

Acute gastric catarrh is another complication of this fever, 



56 TYPHOID FEVER. 

the possible occurrence of which must enter into your prog- 
nosis. A patient may have reached his fourth week, and 
be rapidly convalescing, his desire for food returning ; you 
endeavor to hasten his recovery by increasing the quantity 
of food taken, or by allowing him to partake freely of such 
articles of food as are difficult of digestion. The result of 
this overcrowding, or of imprudence in diet, is irritation 
and inflammation of the enfeebled gastric mucous mem- 
brance. Vomiting of a stringy mucus occurs, which by its 
prostrating effects endangers or destroys the life of your 
already enfeebled patient. I would impress you with the 
importance of exercising the greatest care in regard to the 
diet of patients convalescing from typhoid fever. They 
should be restricted to milk and nutritious broths in mode- 
rate quantity until all danger from this complication shall 
have passed. 

Disturbances of nerve-function have been considered un- 
der the head of symptoms, but, not unfrequently, certain 
brain and nerve lesions are developed which cannot be 
classed under that head. 

Cerebral oedema may complicate a typhoid fever during 
its third week, and give rise to symptoms of a grave char- 
acter. A decided enfeebling of the mental powers and a 
tendency to stupor announces it occurrence. 

Hemorrhagic extravasations on the surface and into the 
substance of the brain, the result of degeneration of the 
walls of the cerebral vessels, occasionally occurs during the 
height of the fever. If the effusion is moderate, no marked 
symptoms are developed ; but if a considerable extravasa- 
tion takes place, it gives rise to symptoms of cerebral com- 
pression. 

Meningeal inflammation is a rare complication. 

The occurrence of any of these complications in any case 
renders the prognosis unfavorable. 

You must remember that during the second or third week 
of the fever certain cerebral disturbances may occur, which 
seem to indicate the existence of some one of these compli- 
cations, when really no cerebral lesion exists. Usually, 
these are present in patients who have had a continuously 



PEOGNOSIS. 57 

high temperature ; in favorable cases they disappear after a 
few days. These have been referred to under the head of 
symptoms. 

You will encounter various other disturbances of the 
nervous system, such as hemiplegia, paraplegia, etc., which 
may simulate those due to lesions of nerve-centres, or local 
forms of paralysis and anaesthesia, which seem to be con- 
fined to individual nerves ; but as these functional disturb- 
ances do not depend upon any anatomical changes, the 
prognosis in such cases is good. 

Those changes in the kidney due to the parenchymatous 
degeneration which usually attends this fever, have been 
already noticed ; but occasionally nephritis is developed as 
a sequela. The urine becomes scanty, is loaded with albu- 
men, and contains blood and casts ; the face and extremities 
become cedematous, and death may occur from uraemia. 
The occurrence of this complication necessarily renders the 
prognosis bad. 

In a few instances under my observation, severe catarrh 
of the bladder has developed during convalescence, greatly 
complicating the case ; in one instance the cystitis was 
accompanied by pyelitis. 

Suppurative inflammation of the cellular tissue of the 
body, or cellulitis, especially of the surface, often compli- 
cates convalescence, and in some cases causes death. It is 
most liable to develop in those parts which have been sub- 
jected to long-continued pressure. Occasionally it is met 
with in the pharynx and along the line of the lymphatics 

Accompanying these cellular inflammations, or occurring 
independently of them, not unfrequently gangrenous inflam- 
mations of the integument occur, giving rise to what has 
been called bed-sores. These gangrenous processes are most 
frequently developed at those points which have been sub- 
jected to the greatest pressure, on account of the position 
of the patient in bed, such as the sacrum, nates, heels, and 
shoulder-blades, etc. In the simplest form of bed-sores 
there is only a superficial loss of substance ; in more severe 
cases the subcutaneous cellular tissue is involved ; and in 
the worst cases the muscles and fibrous tissues. I have met 



58 TYPHOID FEVER. 

with cases where the slough had involved the connective 
tissue and muscles, and laid bare the bony tissue. 

A considerable number of typhoid patients who have 
lived through the fever, die either from the exhausting 
effects of these bed-sores, or from the septic poisoning re- 
sulting therefrom. 

The possible occurrence of these complications must enter 
into the prognosis in every severe case, and the earlier they 
make their appearance the greater the danger. 

We have now completed the list of principal complica- 
tions which are to modify your prognosis in any case of 
typhoid fever. Before leaving the subject, I will say a word 
in regard to the duration and mode of termination of this 
fever. 

Duration. — Its average duration is from three to four 
weeks ; it may terminate in death or recovery at an earlier 
date. A typical case extends over a period of four weeks. 
The period of invasion lasts from one to lave days. The 
period of glandular enlargement continues until about the 
fourteenth day. The period of ulceration extends from the 
twelfth or fourteenth day to sometimes between the twenty- 
first and twenty-eighth. When the fever is protracted be- 
yond the middle of the fourth week, in most instances this 
is due to some complication, or to an extension of the in- 
testinal ulceration. The period of greatest danger is at the 
close of the third week. Death rarely occurs before the 
fourteenth day. The prominent direct causes of death are : 
First, Toxemia ; Second, Asthenia; Third, Suppression 
of the excretory function of the kidneys; Fourth, Hyper- 
emia and osdema of the lungs; Fifth, Intestinal hemor- 
rhage; Sixth, Exhaustive diarrhea; Seventh, Intestinal 
perforation ; Eighth, Peritonitis, with or without intesti- 
nal perforation. In nearly all cases the failure of heart - 
power is directly or indirectly the cause of death. In no 
case can convalescence be said to be fairly established until 
the temperature remains normal for two successive evenings. 
Its termination, like its commencement, is gradual, and it is 
not marked by any critical evacuation or day of crisis. 

Relapses. — After typhoid fever has run its course, and 



RELAPSES. £9 

after the patient is entirely free from fever, quite frequently 
we have a new development of the fever ; these new develop- 
ments are called relapses. Their course corresponds with 
that of the primary attack, only they are of shorter dura- 
f tion. The temperature rises more rapidly, the eruption re- 
appears, the spleen enlarges, the intestinal and abdominal 
symptoms return, and all the prominent symptoms of the 
primary fever are rapidly developed. As a rule, the relapse 
is milder than the primary attack. If it terminates fatally, 
the post-mortem examination shows, in addition to the 
cicatrizing intestinal ulcers of the primary attack, the re- 
cent intestinal changes of the relapse. The lesions of the 
relapse, although of the same character as those of the pri- 
mary attack, are less extensive. 

It is very difficult to give a satisfactory explanation of 
these relapses. Some claim that they are the result of cer- 
tain plans of treatment, especially the cold-water plan. 
This assertion lacks proof. Again, others hold that all re- 
lapses depend upon a new infection. Perhaps this is pos- 
sible if the patient remain in the same locality and has the 
same surroundings as when he had the primary attack ; but 
how shall we explain relapses in those who are removed 
from all the sources of the primary infection? Another 
explanation offered is that a part of the typhoid poison has 
remained in the system, undeveloped during the primary 
attack, and that some time after this has passed the poison 
reproduces itself and sets up a second fever. 

A more recent theory is, that the typhoid poison thrown 
off in the faeces of the patient is reabsorbed and causes the 
relapse. Unquestionably, it is possible for healthy glands 
to become inoculated by sloughs thrown off from those first 
affected. 

In many cases it is impossible to account for the occur- 
rence of the relapse, and all of these explanations as to the 
cause in any case are more or less unsatisfactory. 

In those cases which have come under my own observa- 
tion, I have noticed that the splenic enlargement which has 
existed during the course of the fever does not subside with 
its decline ; and that the tenderness along the line of the 



60 TYPHOID FEVER. 

intestines, especially in the right iliac region, continues 
during the period between the original attack and the re- 
lapse. In some instances, apparently, the relapse has been 
brought on by indiscretion in diet, or by injudicious exer- 
cise on the part of the convalescent patient. Occasionally 
relapses have occurred when great care had been taken 
against any indiscretion or over-exertion. 

There is little doubt but that relapses are of much more 
frequent occurrence in those cases that are treated with 
cathartics during the first week of the fever, than in those 
where cathartics are not employed. 



LECTURE VI. 



TYPHOID FEVER. 

Treatment. 

Befoee speaking in detail of the treatment of typhoid 
fever, I will say a few words concerning its prevention. 

If the modern theory (which I have already given yon) 
of its etiology be accepted, the question naturally arises, 
cannot the typhoid poison be prevented from entering our 
dwellings, or polluting our drinking-water % 

Facts prove almost conclusively that typhoid fever is 
never of spontaneous origin. Should it occur in the locality 
where you may reside, if possible find out its origin. If no 
case has ever before occurred in the locality, endeavor to 
ascertain the manner in which the typhoid poison has been 
introduced. If it is already endemic, limit the disease to 
the first few cases by a most thorough disinfection, and 
remove all those surroundings which favor the reproduction 
of the typhoid poison. 

If the theory is correct, that typhoid fever is dependent 
upon a poison contained in the excrements of a typhoid 
patient, then the poison should be destroyed as soon as it 
is discharged from the body. For this purpose, the intes- 
tinal discharges should be received into a porcelain bed-pan, 
the bottom of which should be covered with a thin layer of 
powdered sulphate of iron ; immediately after the discharge, 
crude muriatic acid, equal in quantity to one- third of the 
fsecal mass, should be poured over it. Never empty the 
discharges of a typhoid patient (no matter how thoroughly 



62 TYPHOID FEVER. 

they may have been disinfected) into the privy or water- 
closet used by the family. Trenches should be dug for 
their reception, and new trenches should be opened every 
few days ; the greatest care should be taken that these 
trenches are not so situated that drainage from them can 
contaminate wells or springs which furnish drinking-water. 
All under-clothing or bed-clothing that may have become 
soiled by the discharges from the bowels, should be imme- 
diately immersed in chlorine water, and thoroughly boiled 
within twenty-four hours. This procedure will certainly 
destroy the infective power of the typhoid poison contained 
in the intestinal discharges, and in the majority of instances 
you will prevent the spread of the fever. 

Repeated observation shows that when one member of a 
family has typhoid fever, not unfrequently it is developed 
in every other member. This spread of the disease can be 
prevented, unless there is some local cause for its develop- 
ment which cannot be reached. 

When its origin is not apparent, the wells, springs, and 
all the sources from whence water is derived for drinking 
and cooking purposes should be carefully and thoroughly 
inspected. Care must be taken that the waste-pipes from 
wells and springs do not pass directly into cesspools or 
sewers, and thus become a means for the conveyance of 
impure gases into the springs and wells. 

The greatest care must also be exercised in regard to home 
drains and sewer-pipes, that they shall be free from leakage 
and obstruction, and that all water-closets, sinks, and 
other openings into them be provided with suitable traps. 

When unpleasant odors are constantly present in dwell- 
ings, especially in sleeping apartments, disinfectants should 
be employed, and the house be thoroughly ventilated. 

When it may be necessary to open drains and cesspools 
in a dwelling for purposes of repair or cleansing, the same 
precautions should be exercised ; these are especially of 
importance during the summer and autumn. 

In conclusion, let me impress upon you this fact, that 
when typhoid fever is carried from the sick to the healthy, 
the evacuations are the chief, if not the only means of con- 



TEEATMENT. 63 

lamination ; consequently, the importance of thoroughly 
disinfecting the excrements of typhoid patients should 
always be borne in mind. 

In this connection the question naturally arises, can we 
not counteract or neutralize the effects of the fever poison 
after it has gained admission into the system, and thus 
prevent the development of typhoid fever % To accomplish 
this, at one time blood-letting was resorted to ; bufc at the 
present day few practitioners would venture to suggest 
such a plan of treatment, and few patients could be found 
willing to submit to it. Emetics were given on the sup- 
position that the fever-poison acted primarily upon the 
mucous membrane of the stomach, and that the offending 
agent might be removed by their early administration, and 
thus its absorption into the system prevented. As it has 
been proved that the typhoid poison can be introduced into 
the system through other channels than the stomach, and 
as experience has shown that emetics have not the power to 
prevent the development of typhoid fever, their use has 
been abandoned. Diaphoretics have also been employed ; 
but there is not the slightest proof that typhoid or any 
fever-poison was ever removed from the system by sweating. 
A patient with some of the premonitory symptoms of fever 
may sweat, be relieved, and at once recover, but such a 
patient has not received the typhoid poison into his system, 
and was not, as is sometimes said, "threatened with 
typhoid fever." 

Notwithstanding the bold affirmation of the author of the 
cold affusion plan of treatment, that if it were resorted to 
before the third day of the disease, it would invariably 
arrest its development, it has failed to stand the test of 
practical experience. 

More recently, sulphate of quinine, administered in large 
doses, has been thought to have the power of arresting the 
development of typhoid fever in the same way that it 
arrests malarial fever, by its anti-periodic power ; but there 
is no evidence that it has any such power, and as a prophy- 
lactic remedy it has been abandoned. 

I might go on almost indefinitely enumerating measures 



64 TYPHOID FEVER. 

which have been resorted to for preventing the develop- 
ment of this fever ; but after the poison has once gained 
entrance into the system, no means have as yet been dis- 
covered by which it can be counteracted or neutralized so 
as to prevent the development of the disease. The duty of 
the physician is to guide the disease, so far as he may 
be able, to a favorable issue, and prevent injury to organs 
essential to life, keeping in mind that a certain definite 
period must elapse before this result can be accomplished. 

Before entering into a detailed account of the treatment 
to be pursued in the management of a case of typhoid 
fever, I will say a few words in reference to the arrange- 
ment of the sick-room of fever patients. Though often 
overlooked, this is a matter of no inconsiderable impor- 
tance, not only as regards the comfort of the patient, but it 
has much to do with the successful issue of the case. 

It is of the greatest importance that a properly qualified 
nurse be selected ; one who has had experience in the care 
of fever patients is to be preferred. In the next place, the 
patient should be placed in a large and well-ventilated 
apartment. All furniture should be removed from the sick- 
room, except those articles which are necessary for the com- 
fort of the patient and the convenience of the attendants. 
Remove the carpets from the floor, place your patient in a 
bed of moderate size in the centre of the room, and let there 
be free ventilation during both day and night. 

The temperature of the apartment (if possible) should be 
kept below 60° F. 

The bed and body linen of the patient should be changed 
daily, and at once be removed from the sick-room and placed 
in a weak solution of chloride of sodium ; especially is this 
important if the patient is having frequent discharges from 
the bowels. The apartment should be kept perfectly quiet, 
the light subdued, and only the attendants should be al- 
lowed in the room. 

These preliminary arrangements having been made, we 
will suppose we have in charge a patient with a mild type 
of typhoid fever. All medicinal interference in such a 
case is unnecessary. The treatment resolves itself into the 



TEEATMEOT. 65 

arrangement of the sick-room and proper diet ; milk is pre- 
ferable, fruits are not to be allowed in any case. In the 
mildest case this care in diet is important, and the patient 
should be kept in bed until convalescence is fully estab- 
lished. This should be insisted upon in the mild as well 
as the severe cases. 

As I have already stated, the temperature in a mild type 
of this fever rarely rises above 103° F. ; therefore there is 
no necessity for resorting to antipyretic measures ; frequent 
sponging of the surface with cold or tepid water, as is most 
agreeable to the patient, will be found of service. 

By far the larger number of cases of this fever are of a 
more severe type, and though in your treatment you must 
be guided by the circumstances which attend each indi- 
vidual case, usually you will be obliged to resort to more 
decided measures. 

Remember that there are no specifics for this disease ; all 
of those which have been proposed and employed have 
either fallen into disuse, or are resorted to only as aids in 
general treatment. 

Typhoid fever is a disease that has certain stages to pass 
through, limited only by days and weeks. There is great 
doubt whether the physician can shorten its duration by a 
single day, but experience warrants the belief that many 
lives may be saved by remedial measures used at the proper 
time, and combined with judicious hygienic management. 

There are critical periods in this disease ; be prepared by 
knowledge and judgment to carry your patient (if possible) 
safely through them. Unquestionably one of the most 
important things to be accomplished is the reduction of 
temperature, or rather the keeping of the temperature below 
a certain standard. Blood-letting, emetics, diaphoretics, 
cathartics, chlorine water, and mineral acids have all been 
resorted to in order to reduce temperature. The last two 
agents were supposed to reduce temperature by neutralizing 
the typhoid poison. At the present day I think there is no 
intelligent physician who imagines he can neutralize the 
typhoid poison, and thus reduce temperature, while only a 
few years ago these agents were supposed to possess such 
5 



bb TYPHOID FEVER. 

power, and were very extensively employed for such a 
purpose by some intelligent physicians. 

The agents which more recently have been employed for 
this purpose, namely, sulphate of quinine and cold applica- 
tions to the surface, are powerful agents in reducing the tem- 
perature and lessening the severity of the disease ; but they 
can never shorten its duration, and if you employ them, ex- 
pecting this result, you will be greatly disappointed. It is 
claimed by many very distinguished observers of the pres- 
ent day that the parenchymatous degenerations of the dif- 
ferent organs and tissues of the body, which are found in 
those who die of typhoid fever, are due to the prolonged 
high temperature which is present during the course of this 
disease ; but as yet there are no facts to prove this asser- 
tion, for the same parenchymatous changes are found in the 
bodies of those who have died of diseases, the course of 
which was not marked by high temperature, and did not 
extend over a period of more than forty-eight hours. So 
far as we are able, to determine by analogy upon what these 
parenchymatous changes depend, we are led to believe that 
the specific poison of the disease has more to do with their 
development than the high rate of temperature. One thing 
must be apparent to every clinical observer : that the 
injurious effects of a prolonged high temperature are early 
and most markedly shown by disturbances of the cerebro- 
spinal system. It is still an unsettled question whether 
these disturbances are due to the primary changes in the 
constituents of the blood, which always accompany a high 
range of temperature, or to the direct effects of the high 
temperature on the nerve centres. 

Whichever view we accept or adopt, the employment of 
those means which have the power of safely reducing tem- 
perature is indicated, and when judiciously used they have 
much to do with the safety of the patient. 

All those means which have been employed for the 
reduction of temperature are included under the general 
term of antipyretics, and the treatment of disease by the 
use of these agents has received the name of antipyretic 
treatment. 



TREATMENT. 67 

Unquestionably the most efficient and reliable of the 
antipyretic agents are the external application of cold by 
means of baths, packs, and effusions, and the internal 
administration of the sulphate of quinine. The quinine is 
not administered to produce any specific action upon the 
typhoid fever poison, but is employed for its antipyretic 
power. There are other antipyretic agents besides these 
two, but they are of so little importance that it is necessary 
to give them only a passing notice after we shall have con- 
sidered these two important ones. 

At the present time the opinion prevails, to a great ex- 
tent, that the application of cold to the surface is the great 
antipyretic in the treatment of fever. This is no new 
teaching. Long ago Dr. Currie recommended the applica- 
tion of cold to the surface of the body for the purpose of 
rapidly reducing temperature, and proved that it had such 
an effect ; yet it was never very generally practised, and 
soon fell into disuse, as there was nothing reliable to guide 
one in its application. As we now have the thermometer 
to guide us in its application, more recently it has been 
resorted to with considerable success. 

I will give you some general rules, which may be of ser- 
vice to you in the use of this antipyretic in the treatment 
of typhoid fever. 

As soon as the axillary temperature in the evening rises 
above 103° F., place the patient in a water-bath having a 
temperature of 70° F. or 80° F., and gradually lower that 
temperature by the addition of cold water or ice, until the 
temperature of the patient begins to fall. You may be 
compelled to lower the temperature of the bath to 60° F. 
before the temperature of the patient is affected ; but the 
lowering of the body temperature must be accomplished by 
the lowering of the temperature of the bath, taking care 
that the latter does not fall below 60° F. When the tem- 
perature begins to fall, renew your thermometrical observa- 
tions every two or three minutes. While the baths are 
being used, the temperature must be taken by placing the 
thermometer in the rectum. If it falls rapidly — that is, 
two or three degrees in five or six minutes — as soon as the 



68 TYPHOID FEVEK. 

fall lias reached 103° F. remove your patient from the bath ; 
if it falls slowly, as soon as it reaches 101° F. he should be 
removed and immediately placed in bed. Never keep the 
patient in the bath until the temperature shall have reached 
the normal standard ; should you do so, he may pass from 
a condition of fever into a state of collapse, as the tempera- 
ture continues to fall for some time after his removal from 
the bath. While in the bath, cold should be applied to the 
head by means of a sponge wet in cold water or by an ice-bag. 

The cold pack is much less eifective than the bath ; but 
if the patient is too feeble to be moved, it may be employed 
with benefit. You should wrap the patient in a sheet wrung 
out of tepid water, and over this sheet apply one wrung out 
of cold water. The latter may be removed as often as it 
becomes warmed ; its application and removal may be con- 
tinued until the desired fall in temperature shall be obtained. 

In severe cases, during the first and second weeks, you 
will find that after the temperature has been reduced by 
the application of cold to the surface, it will begin slowly 
to rise until it reaches its former height. Usually one to 
three hours will elapse before it begins to rise, and from 
two to six before it reaches its former height. You will 
then be obliged to repeat the baths or packs, and to con- 
tinue their use, both day and night, from three to six times 
during the twenty-four hours, if you expect to keep the 
temperature below 103° F., and accomplish anything by 
this plan of treatment. My experience in the use of cold 
applications leads me to believe that unless you are able to 
maintain a low range of temperature after four or five 
baths, you gain very little by their continuance. In other 
words, if, after using the baths for twenty-four hours, the 
temperature of your patient rapidly rises to the same or a 
higher degree than it was before their use was commenced, 
you will obtain little or no benefit from their continuance 
unless you can introduce some other agent which shall 
maintain the low temperature reached by the bath. I am 
also convinced that, after the second week of typhoid fever, 
cold baths should not be employed to reduce temperature, 
for by their continuous use after that period they may do 



TREATMENT. 69 

great harm. The condition of a typhoid patient during the 
first and second week of the fever is very different from 
that during the third and fourth week. During this latter 
period there is great danger of collapse after a cold bath, 
and in several instances I am confident that pulmonary 
complications have been the result. In a few instances the 
temperature can be very rapidly lowered by the application 
of ice-bags to the abdomen. The rapidity with which the 
temperature can be reduced usually depends upon the 
severity of the fever. In some cases, when the patient is 
placed in the cold bath, the temperature will immediately 
begin to fall ; in other cases there will be a gradual reduc- 
tion of temperature as the water is made cooler. In certain 
severe cases, you may keep a patient in a bath of the tem- 
perature of 60° F. for the space of half an hour without 
the temperature falling a degree. These cases are exceed- 
ingly grave in character, and you should use the bath with 
great care. 

Finally, let me impress upon you that in typhoid fever, 
in order to reduce the temperature, you must not indiscrim- 
inately apply cold to the surface of the body. Perhaps there 
is no remedial agent wliich requires greater care and judg- 
ment in its use ; yet doubtless, when judiciously employed, 
the lives of many typhoid patients may be saved, and it is 
equally certain that when injudiciously employed, many 
lives may be destroyed. If you use the cold baths in con- 
junction with other means for reducing temperature (con- 
cerning which I will speak at my next lecture), I am con- 
fident you will accomplish much ; but if you rely only upon 
the baths, in the majority of instances you will be disap- 
pointed in the result. At the present time it seems to me, 
that by some the benefit and power of cold baths in the 
treatment of typhoid fever have been overrated. 

The general condition of your patient and the stage of the 
fever must be considered ; also the effects of the first few 
baths must be carefully noted. 

Should a patient's temperature range at 104° F. or 105° 
F., there is no positive evidence that you must resort to a 
cold bath, or that a cold bath is the best agent to be em- 



70 TYPHOID FEVER. 

ployed for its reduction. Again, if the patient after the 
second or third bath is more quiet, has less delirium (if 
delirium previously existed), if his breathing becomes easy 
and natural, if the heart' s action is more regular and for- 
cible, and he falls asleep and perspires, there can be no ques- 
tion in regard to the beneficial effects of the bath. If, on 
the other hand, the bath is followed by feebler heart' s ac- 
tion, by dusky cheeks, by rapid respiration, and by cold- 
ness of the extremities, from which condition the patient 
rallies slowly and imperfectly, you may be certain that, 
however high the temperature may range, you will do harm 
by continuing the baths. When the extremities are cold, 
or there is profuse hemorrhage from the bowels, or when, 
from any cause, there is great feebleness of the heart' s ac- 
tion, and especially in the case of aged persons, cold baths 
are contraindicated. 

Cold compresses or ice-bags applied to the abdomen, in 
addition to their beneficial effect on the intestinal changes 
which constitute such an important element in the history 
of this fever, often have great power in reducing the gen- 
eral heat of the body. I have also in some instances found 
the body temperature rapidly lowered by injections of ice- 
water into the rectum. Care must be exercised that the 
cold injections are not administered too rapidly or in too 
large quantities. 

Although this mode of abstracting heat and the lowering 
of the body temperature is never so effective as by baths 
and packs, still it has this advantage, that no such compen- 
sating increase in the production of heat follows the use of 
the cold injections as follows the cooling of the external 
surface by the baths. 

In many cases the extreme obstinacy of the fever, which 
resists the most systematic use of cold, as well as the fact 
that some patients cannot bear a sufficiently frequent repe- 
tition of them to effect the desired result, or that there may 
be contra-indications to their use, necessitates the employ- 
ment of other means for the reduction of the body temper- 
ature. To these I shall invite your attention at my next 
lecture. 



LECTURE VII. 



TYPHOID FEVER. 

Treatment {continued). 

We have already considered the antipyretic power of 
cold applications in the treatment of typhoid fever, and I 
will now call your attention to the antipyretic power of the 
sulphate of quinine. 

When quinine is employed as an antipyretic, it must be 
given in large doses ; the administration of two grains every 
two hours, or a larger quantity administered in divided 
doses within a period of twenty -four hours, will not act as 
an antipyretic ; but thirty or forty grains must be adminis- 
tered within a period of two hours. 

If the stomach is irritable, and you fear that a large dose 
will produce vomiting, ten grains may be given every half 
hour until the desired quantity has been administered. 

Usually from four to six hours after the antipyretic dose 
has been taken, the fall in temperature will begin, and in 
about twelve hours it will reach its minimum height ; then 
it will remain stationary from twelve to twenty-four hours. 
After the temperature has once been reduced by the quinine, 
its administration may be discontinued until the tempera- 
ture shall again rise to 105° F. As a rule, the temperature 
rarely ranges as high as before the quinine was administered. 

This mode of administering quinine in antipyretic doses 
to fever patients rarely produces any symptom of cincho- 
nism, other than a transient deafness after the first dose. 
In a large number of cases the temperature can be kept 



72 TYPHOID EEVEK. 

below 103° F. by the sulphate of quinine ; but in very- 
severe cases it will be advisable, and sometimes it will be 
absolutely necessary, to employ not only the quinine, but 
at the same time the cold baths. My rule is, after I have 
reduced the temperature to 101° P., or 102° F., by a cold 
bath, to administer an antipyretic dose of quinine, and thus 
delay the recurring rise of temperature. While the cold 
bath more rapidly reduces temperature, the effect of the 
quinine is more lasting ; consequently, by making use of 
both of these reliable antipyretics during the first two 
weeks, you will be able to control the temperature during 
that time. After this period it is not safe to resort to cold 
baths ; but when the temperature rises above 103° F., oc- 
casionally you may use the cold pack in connection with 
antipyretic doses of quinine. If, during the third and 
fourth weeks, you fail to reduce the temperature by these 
means, administer during the twenty -four hours from ten 
to twenty grains of powdered digitalis — unless the pulse is 
very frequent and irregular — when its use is contra-in- 
dicated. As an antipyretic, digitalis should be adminis- 
tered only when quinine is given. It seems to increase the 
antipyretic power of the quinine, but has little or no power 
when administered alone. 

The use of all these antipyretic remedies must be per 
sisted in until the desired end — the reduction of tempera- 
ture — is accomplished ; but the peculiarities of each patient 
must be studied, and these agents must be so administered 
as to suit each individual case. 

You cannot trust to the judgment of nurses and attend- 
ants, but you must determine for yourself what are the 
requirements in each case. 

The satisfactory results obtained by the systematic use 
of these remedies justifies their employment ; but the exact 
rules which are to govern one in their use, as to manner 
and time, can only be determined by experience. 

All careful observers are aware that great danger attends 
prolonged high temperature ; but it is still an unsettled 
question whether this danger is due to parenchymatous 
changes in the different organs, which some claim are the 



TREATMENT. 73 

result of the high temperature, or to disturbance of the 
nerve centres from the same cause. Whatever may be the 
final settlement of the question, the beneficial results which 
follow the antipyretic treatment of fevers are generally 
admitted ; and my advice to each one of you is, at the 
outset of your professional career to make yourself perfectly 
familiar with the use of these most important and reliable 
antipyretics. 

If you can keep the temperature of your patient at about 
103° F. during the first two weeks of the fever, you have 
accomplished the first and perhaps the most important 
thing in the treatment of this disease. 

Towards the end of the second, or during the third week, 
sometimes earlier, sometimes later, signs of failure of heart, 
power begin to manifest themselves; the pulse becomes 
feeble and irregular ; at times the surface is cool and moist ; 
the patient complains of a sense of exhaustion, perhaps is 
unable to turn in bed ; the tongue assumes a dry, brown 
appearance, and the necessity of supporting the patient 
becomes apparent. This will bring you to the second im- 
portant question in the treatment of this fever, namely, 
wliat means shall be employed to sustain heart power, or, 
as is sometimes said, the vital powers of the patient % 

When a patient, during the second or third week of the 
disease, dies from capillary bronchitis, pulmonary oedema, 
or suddenly passes into a state of coma, failure of heart 
power is the real cause of death. 

In those cases in which, during the early part of the 
fever, you have been compelled to resort to a vigorous anti- 
pyretic treatment, during the third week, although the 
temperature may not rise higher than 101° F., the pulse 
frequently becomes extremely feeble, and reaches 140 per 
minute, the first sound of the heart becomes inaudible, 
muscular tremors, dry tongue, and all the phenomena 
which indicate failure of vital power are present. Under 
such circumstances the use of stimulants seems to be 
urgently demanded. 

There are a few simple rules which may guide you in the 
administration of stimulants in this fever. 



74 TYPHOID FEVER. 

First. — They should never be administered indiscrimi- 
nately — that is, never give a patient stimulants simply be- 
cause he has typhoid fever. 

Second. — When there is reasonable doubt as to the pro- 
priety of giving or withholding stimulants, it is safer to 
withhold them, at least until the signs which indicate their 
use become more marked. 

Third. — In every case, but especially when stimulants 
are not clearly indicated, watch carefully the effect of the 
first few doses. There are few whose experience in the 
treatment of typhoid fever is such as to enable them to 
positively determine, from the appearance of the patient, 
when the administration of stimulants should be com- 
menced. 

Should you commence the administration of stimulants, 
it is necessary to see your patient every two hours, and 
note carefully the effect produced. If you find the tongue 
becoming dry, the patient more restless, the delirium more 
active, the temperature ranging higher, and the pulse more 
and more rapid, you may be certain that stimulants are 
contra-indicated. If, on the other hand, the pulse becomes 
fuller and more regular, if the first sound of the heart is 
more distinctly heard, or, if it has been absent, it has re- 
turned, if the restlessness and delirium are less marked, the 
tongue more moist and the patient more intelligent, you 
may be certain that the time for the administration of stim- 
ulants has arrived. When you have commenced their use, 
it is of the greatest importance that you administer them 
at stated intervals, especially during the night. 

In a severe case of typhoid fever, a free administration of 
stimulants, just at a critical period (which may not last 
more than twenty-four hours), will often be followed by a 
refreshing sleep, and your patient may rapidly pass from 
an apparently hopeless condition to one of convalescence. 

The tliird important thing to be accomplished in the 
management of typhoid fever patients is the maintenance of 
nutrition. You must bear in mind that the primary and 
principal effects of the typhoid poison are manifested in the 
changes which take place in the lymphatics of the gastro- 



TREATMENT. 75 

intestinal tract. Experience lias taught us that the enfee- 
blement of the digestive and assimilative powers, due to 
these glandular changes, which are manifest from the very 
commencement of th.e fever, renders the digestion of solid 
food impossible, and for a long time it has been the rule of 
the profession to allow typhoid fever patients only liquid 
food. 

There has been, and still is, great diversity of opinion in 
regard to the special articles of diet best suited to this class 
of patients. Most medical writers and practitioners claim 
that beef -tea is the proper diet for fever patients ; conse- 
quently it is the rule to pour into these enfeebled stomachs 
a decoction of beef in such quantities as a healthy stomach 
could hardly tolerate, and which, in itself, has little or no 
nutritive element. 

Others claim that gruels are far superior to animal broths, 
and advocate the feeding of fever patients with gruel made 
of barley and other farinaceous substances, to the exclusion 
of every other article of diet ; yet gruels furnish few ele- 
ments essential to the nourishment of a physical organiza- 
tion struggling against a subtle poison, and rapidly wasting 
with a burning fever, and starvation is the necessary result 
of a restriction to gruel diet. 

There is no disease in which a waste of all the tissues of 
the body goes on so rapidly as in typhoid fever ; and milk 
is an article of diet which furnishes the elements of nutri- 
tion necessary to repair this rapid waste, and there are not 
the objections to its use which there are against animal 
broths and gruels. Although there have been, and still are, 
in some quarters, strong objections against its use as an arti- 
cle of diet in fevers, recently it has been regarded with 
more favor, and those who have had most extended oppor- 
tunities for testing its nutritive qualities have come to regard 
it as the only article of diet required by typhoid patients. 
In it we not only find all the elements required for repairing 
the rapidly wasting tissues, but they are in a condition to 
be most readily assimilated by the enfeebled digestive ap- 
paratus. 

In order to make the milk more digestible, it may be di- 



76 TYPHOID FEVER. 

luted with lime-water. The lime-water is an antiseptic, and 
allays irritability of the stomach and intestines. The quan- 
tity of milk is not limited ; the patient may take all his 
stomach will digest — usually patients will take from four 
to six quarts in the twenty-four hours. 

After the patient has passed into the fourth week of the 
disease, you may find it necessary to administer cream and 
the yolk of eggs in connection with the milk. 

Having considered the three most important things to be 
accomplished in the general management of typhoid fever, 
I now come to the treatment of the accidents of the disease. 

Diaerhcea. — I have told you that diarrhoea is one of the 
common symptoms of this fever ; but it is one of which 
medical writers have taken special notice, and for the relief 
of which different means have been employed. 

Let us for a moment notice the chain of phenomena of 
which diarrhoea is a link. The poison which produces this 
fever unquestionably has a specific action upon the intes- 
tinal glands and lymphatics. It is here that we find the 
characteristic lesions of the disease, and it is scarcely ques- 
tioned that the typhoid poison, to a great extent, gains 
entrance to the system through these glands and lymphat- 
ics, and here produces the primary irritation. Following 
the irritation and inflammation of the follicles, other por- 
tions of the mucous membrane become involved, and we 
have a catarrhal inflammation of the mucous membrane of 
the intestinal tract. The necessary consequence of this is 
a diarrhoeal discharge. Is this diarrhoea to eliminate the 
fever poison ? Certainly not. It is simply an indication 
that these intestinal changes are going on ; it is not due 
to the elimination of the typhoid fever poison, but to the 
inflammation which the fever poison has excited in the 
intestinal glands, and the subsequent intestinal catarrh. 
When the diarrhoea is present in the earlier period of the 
disease, it is better to let it alone. The question may be 
asked, will it not exhaust the patient ? During the earlier 
period of the fever (the first and second week) the danger 
is very slight. It has been proposed to treat this diarrhoea, 
which makes its appearance early in the disease, with alka- 



TREATMENT. 77 

lies, bismuth, pepsin, etc. It is claimed, if these remedies 
be administered, diarrhoea can be prevented, or, if it already 
exists, that it can be controlled. Theoretically, I see no 
reason for employing alkaline remedies, for the diarrhoea! 
discharges are always strongly alkaline, and, from clinical 
observation, I am convinced that bismuth, pepsin, etc., 
have little or no effect either in controlling the diarrhoea 
or in preventing the intestinal changes which produce it. 
When diarrhoea commences late in the disease (during the 
latter part of the third, or during the fourth week of 
the fever), it is of a very different character from that 
which occurs during the first and second weeks. Ulcera- 
tion of the intestinal glands, and perhaps sloughing, has 
been established, and, in addition to the extensive local 
changes, there is a septic element which enters into the 
causation of the diarrhoea at this stage. Besides, the in- 
creased peristaltic action of the intestines, which attends 
the diarrhoea, favors an extension of the inflammatory pro- 
cesses to the peritoneum, especially that portion which 
covers the intestine, which corresponds to Peyer s patches. 
In view of these facts, the diarrhoea should be arrested or 
held in check. For the accomplishment of this, there is 
but one remedy which can be relied upon — that is, opium. 
My experience is against the use of astringents. If opium 
will not arrest it, you may expect little aid from astringents 
combined with opium as they are usually administered. 

The use of opium is objected to by some, who claim that 
it diminishes the power of the heart' s action ; but in this 
disease, when administered in small doses, it seems to me 
to increase rather than diminish the heart-power. It is ac- 
knowledged that opium, more than any other drug, arrests 
the peristaltic action of the intestines ; and that is what we 
wish to accomplish when diarrhoea is present during the 
third and fourth week of typhoid fever. 

Tympanitis. — You will recollect that the tympanitis, 
which is sometimes so troublesome a symptom in typhoid 
i'ever, is due to gaseous distention of the intestines. Some 
assert that this gaseous accumulation is due to fermentative 
processes going on in the intestines ; consequently that the 



78 TYPHOID FEVER. 

use of antiseptic remedies is indicated, such as muriatic 
acid, chlorate of potash, pepsin, etc. When this has proved 
a distressing symptom, I have usually found relief to be 
obtained by the application of turpentine stupes to the ab- 
domen. Some claim that if turpentine be administered 
internally, from the beginning to the end of typhoid fever, 
that tympanitis and the intestinal changes which lead to it 
and to the diarrhoea are much less severe. I am confident 
that the turpentine treatment, as it is called, does not have 
the controlling influence over this fever which has been 
claimed for it ; but I am also certain that it is our most 
reliable agent for the relief of the tympanitis. 

Intestinal Hemorrhage. — Hemorrhage from the bow- 
els in typhoid fever (as I have already stated) is a serious 
accident, and may cause death by producing a fatal ex- 
haustion. 

When it occurs early in the fever, usually it requires no 
treatment ; but when it occurs during the third or fourth 
week, or after convalescence is apparently fully established, 
it must be arrested as promptly as possible. 

The occurrence of severe intestinal hemorrhages may 
sometimes be prevented by keeping the patient in bed. A 
typhoid fever patient should not be allowed to get out of 
bed from the beginning of the attack until convalescence is 
fully established. Especially is this of importance if the 
case is a severe one, and attended by symptoms that indi- 
cate extensive intestinal lesions. 

When hemorrhage from the intestines does occur during 
the third or fourth week of the fever, at once semi-narcotize 
your patient by the administration of opium in small doses 
at short intervals. Absolute rest of the body must be in- 
sisted on, the patient must not be turned on the side or 
moved in bed, and an ice-bag should be applied over the 
abdomen. I doubt if any good results can be accomplished 
by the use of astringents, either by enemata or by the 
mouth, as it is not known that they even reach the seat of 
the hemorrhage, although gallic acid and the persulphate 
of iron are usually recommended in cases of intestinal hem- 
orrhage occurring in typhoid fever. If the hemorrhage is 



TREATMENT. 79 

profuse, it may be necessary to keep your patient under the 
influence of the opium for a week or ten days ; in such cases 
the internal use of turpentine in connection with the opium 
will be found of service. 

Peritonitis. — When perforation of the intestine occurs, 
the case may be regarded as hopeless ; death takes place 
usually within twenty-four hours ; death occurs as the 
result of general peritonitis ; no plan of treatment avails 
anything. If the peritonitis occurs without perforation, 
from the extension of the inflammatory process from the 
intestinal ulcers to the peritoneum, by bringing your 
patient; rapidly into a state of semi-narcotism and holding 
him there for five or six days, you may prevent the ex- 
tension of the peritonitis and thus save life. Such a case 
you are to treat in every respect as one of localized perito- 
nitis. 

After recovery from an intestinal hemorrhage or a local- 
ized peritonitis in typhoid fever, be exceedingly careful 
about the administration of cathartics or enemata ; either 
may jeopardize the life of your patient. The bowels will 
move spontaneously after a time, even though the use of 
opium be continued, and no harm will follow should two or 
three weeks pass without a movement from them. 

When the stomach is irritable, the hypodermic injection 
of morphine is preferable to opium administered by the 
mouth. This is given in sufficiently large quantities to 
paralyze the peristaltic movement of the intestines. 

Bronchitis. — I have already stated that catarrh of the 
larger bronchial tubes is present in all severe cases of 
typhoid fever. No special treatment is required for its 
management ; but, if the bronchitis becomes capillary, 
great relief will be obtained from the application of dry 
cups to the chest and the internal administration of car- 
bonate of ammonia. Vapor inhalations will also be found 
of service in severe cases. 

Pneumonia. — The pneumonia which complicates typhoid 
fever in nearly every case is lobular in character. The 
signs which indicate its occurrence are sudden rise of tem- 
perature, increased frequency of respiration, and the physi- 



80 TYPHOID EEVER. 

cal signs of localized pulmonary consolidation ; cough and 
expectoration are rarely present. 

Its occurrence is always an indication that stimulants 
should be administered. If they are being administered, 
they should be increased in quantity. To prevent or relieve 
the hypostatic congestion of other portions of the lung, 
which frequently accompanies pneumonic development, the 
heart-power must be increased, and the position of the 
patient changed. 

Laryngitis. — For the relief of the laryngitis which occa- 
sionally complicates typhoid fever, a small blister may be 
applied on either side below the angle of the jaw, and the 
whole neck enveloped in a poultice. If these measures 
fail, and suffocation appears imminent, tracheotomy should 
be resorted to without delay. 

' Subacute gastric catarrh, occurring as a complication 
during convalescence from the fever, can only be managed 
successfully by giving the stomach rest as far as possi- 
ble, restricting the diet to a single tablespoonful of milk 
at a time, and applying hot fomentations over the epigas- 
trium. 

Bed-sores. — The severer forms of bed-sores are the most 
intractable complications we have to combat. Fortunately, 
the severer forms are much less frequently met with under 
the more recent plan of treatment ; and, if they do occur, 
they are superficial and limited to small spots. Scrupulous 
cleanliness is one of the principal means for preventing 
their development. So long as there are no erosions, the 
parts should be frequently bathed in spirits of camphor, 
and the points of attack should be relieved from all pres- 
sure. If the sores penetrate the integument, they should 
be frequently washed with a weak solution of carbolic 
acid, or brushed over with equal parts of balsam peru and 
balsam copaiva and afterwards covered with dry lint or 
lint covered with vaseline. 

The most unfavorable cases are those in which the point 
of pressure caused by the weight of the body becomes gan- 
grenous. In such cases, by some a continuous warm bath 
is recommended. As soon as sloughing takes place, and 



TKEATMEOT. 81 

the parts separate, they should be dressed with lint satu- 
rated with balsam of peru and carbolic acid. 

As has been already stated, diarrhoea is usually present 
in the early period of this fever ; but sometimes there is 
constipation. The question arises, is the administration of 
cathartics ever admissible in typhoid fever? If so, what 
cathartic shall be employed? There is great diversity of 
opinion upon these points. One recommends the adminis- 
tration of rhubarb, another advises alkaline cathartics, and 
another would give calomel. 

Quite diverse views are still held in regard to what the 
answer to this question should be. Recently, certain 
observers of extended experience have claimed that there 
is sufficient reason for the belief that a portion of the 
typhoid poison lodged in the alimentary tract may be 
expelled by the timely administration of cathartics, and 
thus the severity of the fever be mitigated and its duration 
shortened. Recent German writers claim that calomel, 
concerning the favorable action of which in this fever so 
much has been said and written, acts beneficially only as a 
cathartic. Those who favor the administration of cathar- 
tics recommend their use mainly during the first week of 
the disease. 

On the other hand, equally competent observers maintain 
that the intestinal changes are augmented, and rendered 
more extensive by the action of cathartics ; that the normal 
course of the fever is interfered with ; and that in a larg^ 
proportion of cases where intestinal and peritoneal compli- 
cations occur, hypercatharsis has been induced at an early 
period of the fever by the administration of cathartics for 
the purpose of shortening its duration. My own experience 
leads me to exercise the greatest caution in the administra- 
tion of cathartics in any stage of this fever. I am confident 
that the routine practice of administering purgative medi- 
cines in the early stage of typhoid fever can only be fol- 
lowed by a threefold injury : 

First. — The patient is weakened. 

Second. — The local intestinal lesions are increased. 

Third. — Perforating peritonitis is more liable to occur. 
6 



82 TYPHOID FEVER. 

The administration of cathartics as an eliminative pro- 
cedure has neither reason nor experience to sustain it. 

Before speaking of the management of the convalescence 
of typhoid fever, I will make a few general remarks on the 
use of anodynes for the relief of certain troublesome ner- 
vous phenomena. 

I have stated to you that among the earliest, most fre- 
quent, and often most prominent nervous symptoms in this 
fever is headache, but it is seldom very violent or of long 
continuance. 

Should it be severe, not readily relieved by fomenting the 
forehead and temples with warm water, or should it give 
place to active delirium, and other severe nervous disturb- 
ances, the question presents itself, shall anodynes be 
administered ? If you decide to use them, the most reliable 
of this class of remedies is opium. 

Us a ally, the condition of the pupil of the eye will serve 
to indicate to us whether opium shall or shall not be 
administered. A contracted or "pin-hole" pupil maybe 
considered to contra-indicate its use, though there are excep- 
tional cases in which opium acts favorably, notwithstanding 
this condition of the pupil. 

Opium should be given with great caution whenever 
signs of cyanosis are present. In all cases of typhoid fever, 
it is safer to administer opium in small and repeated doses 
than to venture upon the administration of one large dose. 

There are other anodynes which you will sometimes find 
of service, such as hyoscyamus, chloral, and the bromides. 
I would caution you against administering too large doses 
of chloral ; the desired effect can generally be produced by 
ten or fifteen grains. If the first dose fails to relieve, a sec- 
ond may be administered at the expiration of two hours. 
This remedy is said to have a special value in quieting the 
active delirium, which is sometimes so troublesome, but my 
own experience in its use has not been favorable. When 
anodynes have failed to give relief to typhoid fever 
patients, who have been delirious aud somnolent for days, 
they will sometimes become quiet and fall asleep immedi- 
ate! v after the free administration of stimulants. Those 



TREATMENT. 83 

cases in which the nervous symptoms are due to an ansemic 
condition of the brain, associated with a weak heart and a 
nagging circulation, are most likely to be benefited by the 
use of stimulants. In those cases in which subsultus 
becomes very marked and there is a general tremor, jacti- 
tation, and restlessness, I have seen most happy effects pro- 
duced by the use of hypodermic injections of sulphuric 
ether. I would use, as an average quantity, four drachms 
given in injections of one drachm each, in different places. 

The same watchful care should be taken of a typhoid 
fever patient during convalescence as during the active 
period of the fever. 

The number of typhoid patients who die during convales- 
cence is proportionally large. Frequently this is due to 
the fact that the physician has laid down no strict rules to 
be observed as to diet and exercise, and frequently from 
the non-observance of such rules when they have been given. 

The diet of fever patients during this period should be 
carefully watched. Allow your patient to eat frequently, 
but only small quantities of food should be taken at a time, 
so that the gastric juice secreted by the enfeebled stomach 
may be sufficient for its complete digestion. All indigesti- 
ble articles of food, and those which furnish a large amount 
of waste, should be strictly forbidden. An apparently 
insignificant disturbance of the stomach, a slight vomiting, 
or a moderate diarrhoea occurring during the period of con- 
valescence should be regarded as dangerous, for any one of 
these may induce a subacute gastritis, or lead to intestinal 
perforation and a fatal peritonitis. It is obvious that while 
the intestinal ulcers are healing, much mischief may be 
done by improper diet. 

Notwithstanding the cravings of the patient's appetite, 
the diet must be restricted to such articles as milk, cream, 
gruels, jellies, and animal broths. Solid food must be 
strictly forbidden, especially meats, vegetables, and fruits. 
If diarrhoea is present during convalescence it is far safer to 
restrict the patient to milk and cream. All exercise, except 
simply walking around the sick-room, should be prohibited. 
I have had patients convalescing from typhoid fever sink 



84 TYPHOID FEVER. 

rapidly after a long ride, or after indulging in some violent 
and fatiguing physical exercise. It is of the greatest impor- 
tance that this class of patients should keep in the recum- 
bent or semi-recumbent posture until the cicatrization of 
the intestinal ulcers is completed, which in some instances 
does not take place for two or three weeks after convales- 
cence is well established. If convalescence is slow, small 
doses of quinine, iron, and cod-liver oil are of service. They 
should be given after the patient has taken food. 

When, during the period of convalescence, diarrhoea is 
persistent, the patient should be kept in bed, and some of 
the vegetable astringents, such as catechu, hsematoxylon, 
may be employed. 

In many cases it is important that you should take the 
evening temperature for at least two weeks after the com- 
mencement of convalescence, for by its range you will be 
able the more accurately to determine the exact condition 
of your patient. 

When convalescence is delayed, so that at the end of 
four or live weeks the patient has not regained strength, 
change of air is indicated. 



LECTUEE VIII. 



YELLOW FEVEK. 

Morbid Anatomy. — Etiology. — Symptoms. 

This morning I will commence the history of the second 
in the list of miasmatic-contagions fevers, namely, Yellow 
Fever. 

This fever has received its name from a yellow discolora- 
tion of the skin, which is a part of its clinical history. 

The term, yellow fever, has been generally adopted by 
American, English, French, and German writers, and it is 
not necessary to mention the long list of obsolete names 
which have been applied to this disease by different writers. 

Morbid Anatomy. — We find that the anatomical changes 
which take place in the different organs and tissues of the 
body during the course of this fever, in some respects are 
similar to those which occur in miasmatic and contagious 
fevers, allying the disease more or less nearly to each of 
these classes of fever. 

Although these different types of fever have many points 
of resemblance in their anatomical lesions, as well as in 
their general history, each has its own distinguishing char- 
acteristics which mark it as a distinct and specific disease. 

The characteristic lesion (if we may so call it) of yellow 
fever is to be found in the liver. This organ is not much 
increased in size, but there is a striking and uniform change 
in its color. Sometimes it is of the color of fresh butter, 



86 YELLOW FEVER. 

sometimes of a mustard color, and sometimes the color of 
coffee and milk, or chocolate color. In most instances this 
change occurs throughout the entire organ ; occasionally, 
it is confined to one lobe, or to a small portion of a lobe. 
With this change in color there is a diminution in the quan- 
tity of blood in the liver, so that it contains less blood than 
normal. It has a dry appearance, is softer than normal, 
breaking down readily on firm pressure. When a section is 
placed under the microscope, it will be seen that there has 
been infiltration of the hepatic cells with oil-globules. In 
fact, all of the liver cells are more or less filled with oil-glob- 
ules. Sometimes the change is a granular one, the nuclei 
of the cells have disappeared, or become obscured ; in other 
instances, the entire liver cells have filled with large oil-glob- 
ules, but the form of the cells has not changed. 

This change has received the name of acute fatty degen- 
eration. In its gross appearance, as well as in its minute 
anatomical changes, the liver resembles the fatty degenera- 
tion of the liver of rum-drinkers. Besides this, there is no 
change of any importance observed in the liver in yellow 
fever, except it may be slight extravasations of blood upon 
its surface, rarely in its substance. 

Mucous Membranes. — You will find the mucous mem- 
brane of the intestinal track, as also that of the larynx, the 
seat of a more or less severe acute catarrh. The vessels of 
the mucous surfaces, especially the veins, will present a 
turgid appearance ; and so intense is the hypersemia that at 
points they will present a varicose appearance. If there 
is a uniform congestion throughout the entire extent of the 
intestinal track, you will notice here and there little blood 
extravasations or ecchymotic spots. The whole track con- 
tains a greater or less quantity of fluid blood. Frequently 
the mucous membrane of the stomach is found thickened, 
reddened, and softened, sometimes with quite extensive 
blood extravasations. The contents of the stomach corre- 
spond to matters vomited during life, which I shall more 
fully describe under the head of symptoms. 

Heart. — The heart is soft and flabby, lighter in color 
than normal, and will be found to have undergone degen- 



MORBID ANATOMY. 87 

erative changes similar to those which take place in its 
muscular tissue in tj^phoid fever. These changes undoubt- 
edly do not depend upon high temperature, for a very 
high temperature is rarely present in yellow fever. The 
normal outline of the heart is lost, and it breaks down 
readily on firm pressure. The more severe the fever, and 
the longer its duration, the more extensive will be the 
parenchymatous degeneration. The pericardium usually 
contains one or two ounces of blood-stained serum. Par- 
tially organized clots are found in the heart cavities ; these 
often extend for some distance into the vessels. They are 
the result of a slowing of the circulation from feebleness 
of the heart power, and, in most instances, are formed just 
prior to death, although they are not the cause of death. 

Lungs. — Usually the lungs are the seat of hemorrhagic 
infarctions. In fact, you will rarely make an autopsy upon 
one who has died of yellow fever without finding infarctions 
in the lungs, and sometimes they will be quite numerous. 
Diffused pulmonary apoplexies often occur, which may in- 
volve a large portion of a lobe. Under such circumstances 
the lung tissue will be broken down and occupied by large 
blood-clots. Spots of ecchymosis will also be found under 
the pulmonary and costal pleura. 

Kidneys. — The kidneys are always more or less increased 
in size. This increase is due to swelling of the cortical sub- 
stance, which is the seat of a more or less extensive fatty 
metamorphosis. It is a true parenchymatous nephritis, in 
which the fatty stage is very rapidly reached. You will 
find the uriniferous tubules crowded with oil-globules ; in 
some places the tubes are denuded of epithelium ; in other 
places they are filled with broken-down epithelium, which 
is undergoing a fatty and granular change. The pelvis of 
the kidneys is frequently the seat of acute catarrh, and evi- 
dences of catarrhal inflammation may be found along the 
ureters and in the bladder. The mucous membrane of the 
bladder will also be found to be the seat of punctate ecchy- 
moses. In fact, in all the mucous surfaces of the body 
large and small ecchymoses are found. 

Brain. — The brain and its membranes, as well as the spi- 



88 YELLOW FEVER. 

nal cord, present no marked change. They are often hyper- 
aemic, and are frequently the seat of punctate extravasation. 

Spleen. — The spleen is but slightly, if at all enlarged, 
is of a darker color and of a softer consistency than nor- 
mal. 

Skin. — The skin varies in color from a bright yellow to a 
dark orange. It may be the seat of ecchymoses or of large 
extravasations. 

Blood. — There is one other important lesion of this dis- 
ease, namely, the changes which take place in the blood. 
There is nothing characteristic about them ; they are simi- 
lar in character to those which take place in the blood 
in typhus and typhoid fever, although more extensive than 
in either. The blood coagulates much less rapidly and 
much less perfectly than normal blood. This loss of coagu- 
lating power may be due to a diminution in its fibrin, or to 
a loss of coagulating power in the fibrin. These changes 
were noticed by the earliest writers on this disease. The 
blood is changed in color, being darker than healthy blood. 
The blood-globules, instead of retaining their rounded out- 
line, have their edges serrated and break down, There is 
no free pigment, such as is found in the different forms of 
malarial fever. 

Blood taken from yellow fever patients rapidly undergoes 
ammoniacal changes. 

Some of the pathological lesions of yellow fever very 
closely resemble those of relapsing fever. In both we find 
similar changes in the blood and a tendency to hemorrhages. 

Etiology. — To the student of the literature of this dis- 
ease, there is no part of its history so uncertain or so con- 
fusing as that of its etiology. Equally competent observers 
widely differ, and often hold diametrically opposite views 
in regard to it. 

In our own city, some very bitter monographs have been 
written by medical men holding antagonistic views in regard 
to the causation of yellow fever. 

I shall endeavor briefly to state well-authenticated facts 
concerning its causation, as far as possible making no 
mention of mere theories. 



ETIOLOGY. 89 

Under this head, the first question that presents itself is, 
In what localities does the fever prevail ? 

It is rarely met with north of 40° north latitude, or 
south of 20° south latitude. It prevails much more fre- 
quently on the western than on the eastern hemisphere, 
and in certain portions of Europe and America than in 
Africa. It is almost exclusively confined to commercial 
seaports, and is sometimes circumscribed to very narrow 
limits within those seaports. A certain amount of moist- 
ure, either on the surface or in the substance of the soil, 
is necessary for its production. There must also be present 
decaying animal and vegetable matter. For the produc- 
tion of the miasm which causes malarial fevers vegetable 
decomposition is sufficient, but for the development of 
yellow fever, both animal and vegetable decomposition is 
necessary. A high temperature is necessary to its develop- 
ment. The average temperature for the twenty-four hours 
must be above 77° F. 

The period of the year during which yellow fever prevails 
depends upon climate and temperature. In the United 
States, it has usually appeared in July or August, and dis- 
appeared upon the first frost. The great epidemic of 
yellow fever in New York City, in 1795, began early in 
August, and disappeared about the middle of Octo- 
ber. 

Undoubtedly, this fever is indigenous in certain locali- 
ties. There are certain seaports along our southern coasts, 
and certain islands of the sea, where it is developed when- 
ever the necessary atmospheric conditions are present. 
Especially is it a disease of hot climates, and, in localities 
that are subject to it, it is more likely to prevail in very 
warm and wet than in cold and dry seasons. It may be 
endemic or epidemic. Sporadic cases are of rare occur- 
rence, even in localities where it is indigenous. Some races 
more than others are subjects of this fever. The African 
race is most exempt from it. 

A prolonged residence in a district where yellow fever is 
indigenous renders an individual less liable to contract the 
fever. Possibly a person may become acclimated to the 



90 YELLOW FEVER. 

disease. Having once had the disease is a partial, though, 
not complete, protection against a second attack. 

North- westerly winds seem to arrest, while south-easterly 
winds seem to favor its development. In other words, 
when south-easterly winds are prevailing, the epidemic 
spreads and increases in severity, while, if the wind changes 
to the north-west, its progress is arrested. Whenever the 
temperature falls below the freezing point, no matter how 
pestiferous a region may have been, nothing more need be 
feared from the spread of the disease. 

These are some of the conditions which are necessary for 
the development and spread or arrestation of yellow 
fever. 

Now, the question arises, What is the nature of the 
poison that produces the fever ? Is it a miasm or a conta- 
gion ? There can be no question but that it is a poison in 
many respects similar to that of typhoid fever, which can 
be conveyed in some way from one individual to another, 
or rather that, when certain atmospheric conditions are 
present in connection with animal and vegetable decom- 
position, the introduction of the specific yellow fever poison 
is followed by its rapid reproduction. When it has been 
so reproduced, it may be received into the human system 
and give rise to morbid processes, attended by certain clin- 
ical phenomena which are characteristic of this disease. 
Thus far chemical and microscopical research has afforded 
no positive information in regard to the nature of the yel- 
low fever poison, but there can be no question as to the 
existence of such a distinct and specific poison, and it 
would seem, from the conditions necessary to its develop- 
ment and the manner of its conveyance, that it is in some 
respects of the nature of a miasm, and in other respects 
that of a contagion. You may nave yellow fever, remit- 
tent fever, and typhoid fever, all prevailing at the same 
time in a locality, yet each of these three diseases will run 
its individual course, and no one will lapse into another. 

The question now comes to us, Is yellow fever contagi- 
ous f There are three leading doctrines upon this point. 

First. — The doctrine of unqualified contagion, which 



ETIOLOGY. 91 

attributes to the disease an absolute and unqualified con- 
tagious character. 

Second. — The doctrine of non-contagion, which maintains 
that the disease is never transmitted directly from one per- 
son to another. 

Third. — The doctrine of contingent contagion, which 
teaches that the disease cannot be conveyed from one indi- 
vidual to another, except in a yellow fever atmosphere ; that 
is, when yellow fever is prevailing in any locality, in that 
locality it may be transmitted from one person to another. 

After carefully studying the recorded observations and 
weighing the statements of the advocates of these different 
doctrines, I can unhesitatingly state to you that the majority 
of those who have had the most extended opportunities for 
studying this disease, deny its contagious character, and 
very strongly advocate the doctrine of non-contagion. 

Some German writers claim that the germ in yellow 
fever, as in typhoid fever, cannot be conveyed directly from 
the sick to the healthy, but that it must first be deposited 
in decomposing animal and vegetable matter, and that wher- 
ever animal and vegetable decomposition is going on, there 
are present the conditions necessary for the rapid reproduc- 
tion of the yellow fever germ. One thing is certain, that 
whenever yellow fever prevails as an epidemic, there is 
present animal and vegetable decomposition. The disease 
prevails only where men are crowded together, as in ships, 
and around the docks and wharves of seaports, and in the 
filthy streets and habitations of such localities. 

In some few instances, evidence exists that yellow fever 
breaking out in the hold of a vessel has been circumscribed 
to certain portions of the hold by free ventilation, not a 
case occurring save within certain well-defined limits, within 
which ventilation was impracticable. 

It would therefore seem that yellow fever can be pro- 
duced only when the atmosphere has become loaded with 
emanations from animal and vegetable decomposition, to 
which must be added the specific yellow-fever poison before 
the fever can be propagated from the sick to the healthy. 

While the advocates of the doctrine of non- contagion are 



92 YELLOW FEVER. 

positive as to the non-contagious character of yellow fever, 
they are equally certain that it is a portable disease, that 
is, that it can be conveyed from one locality to another by 
means of clothing, merchandise, and in the holds of vessels. 
They also believe, when yellow fever poison is thus intro- 
duced into healthy localities which are suited by tempera- 
ture and the presence of animal and vegetable decomposition 
to its reproduction, that it rapidly and repeatedly repro- 
duces itself, and in this way epidemics of yellow fever may 
be developed in localities which are usually free from the 
disease. Consequently, it is a disease which should be 
guarded against in any seaport by a vigorous quarantine. 

How long yellow fever poison may retain its vitality is 
not yet positively determined, but that the period is a very 
long one there can be no question. 

One may visit a locality where yellow fever is prevailing 
and remain in it for a considerable time, and not convey 
the poison in the clothing beyond the boundaries of the 
district where the disease is prevailing. In order to the con- 
veyance of the poison beyond these limits, it is necessary 
that the clothing become so saturated with the poison that 
it will not become neutralized when exposed to the air of a 
non-infected district. 

I have briefly stated to you all of the important well- 
ascertained facts that bear upon this vexed question. In 
conclusion, it may be stated that with the written history 
of the disease before one, there is not sufficient evidence to 
lead to the acceptance either of the doctrine of contagion, or 
of contingent contagion. It seems to me there need be no fear 
of contracting the disease by visiting those sick with yellow 
fever- in a yellow fever district, unless such visits are very 
much prolonged. The poison of yellow fever, as met with 
in the holds of vessels, sometimes is so concentrated that 
a very short exposure is sufficient to overwhelm the nervous 
system, and give rise to very urgent nervous phenomena, 
which are soon followed by the development of the fever, 
and from such exposure it is possible to convey the poisoi 
in the clothing. 

The length of the period of incubation varies from twelve 



SYMPTOMS. 93 

hours to four or five days ; it is claimed by some that this 
period of incubation may extend over a period of several 
weeks. When the exposure is followed in a few hours by 
the fever, the yellow fever poison must necessarily be very 
concentrated. 

Symptoms. — The development of yellow fever may or may 
not be preceded by premonitory symptoms, such as head- 
ache, pain in the limbs, and loss of appetite. If these symp- 
toms are present, they are by no means characteristic of the 
fever. In nearly every instance the disease is ushered in 
by a distinct chill ; in no disease, unless it may be puer- 
peral fever, is a chill so invariably an ushering-in symptom 
as in yellow fever. While apparently in the most perfect 
health, while at work, or even while asleep, patients will 
be seized with a slight or severe chill, and immediately be- 
come seriously ill, taking their beds in the most disheart- 
ened manner. 

You will remember that I stated to you that there were 
both mild and severe types of typhoid fever, and that they 
differed only in degree, not in kind ; so also is the case in 
yellow fever, and you must remember this fact when con- 
sidering the symptoms of this fever. 

The outline of the clinical history is very nearly the same 
in a mild as in a severe type of the fever. Following the 
chill or rigor which ushers in the attack, there is supra- 
orbital headache, pains in the back and limbs, which are 
especially severe in the calves of the legs. The counte- 
nance is flushed, the conjunctiva congested ; the eye has a 
peculiar lustre and a staring look. The temperature rises 
rapidly, and reaches 102° F. within a few hours after the 
chill. The temperature in yellow fever varies very much 
in different cases. In some cases it never rises above 102° 
F., while in some severe epidemics it has been recorded as 
high as 110° F. Such a temperature is very seldom 
reached. By the end of the second day the temperature 
usually reaches its maximum height, which rarely is higher 
than 105° F. In this country, according to records made, the 
temperature has rarely risen higher than 104° F. This fever 
is not characterized by so high a range of temperature as is 



94 YELLOW FEVER. 

met with in almost all the other varieties of fever. From 
the second to the fourth day the temperature variations are 
slight, and do not amount to distinct remissions. By the 
fourth day, if not before, the temperature falls very rap- 
idly, so that in twelve hours the normal standard may be 
reached ; usually, however, it does not fall below 100° F. 
This fall constitutes a distinct remission. This period of 
remission may last from a few hours to two or three days, 
after which time the temperature again rises, and rapidly 
reaches 104° F., or even rises higher ; then it remains sta- 
tionary from twenty-four to forty-eight hours, after which 
time it falls to the normal standard, where it remains until 
convalescence is established. 

In accordance with the temperature variations, the dis- 
ease may be divided into three stages : a first stage, or 
stage of invasion ; a second stage, or stage of remission ; 
and a third stage, or stage of exacerbation. 

Some writers have divided the disease into a febrile 
stage, or stage of exacerbation, a passive stage, or stage of 
remission, and a stage of collapse. 



LECTURE IX 



YELLOW FEVER. 



Symptoms {continued). — Differential Diagnosis. — Prog- 
nosis. — Treatment. 



This morning I would invite your attention to the farther 
study of the symptoms of yellow fever. I have stated to 
you that in the majority of instances this fever is ushered 
in by a distinct chill ; usually, this is not prolonged ; follow- 
ing the chill there is a rapid rise in temperature, which, by 
the third or fourth day, reaches its maximum height, from 
103° F. to 107° F. This rise in temperature may be accom- 
panied by dryness of the surface, or the surface of the body 
may be bathed in a profuse perspiration. Sometimes, after 
the chill has subsided, there is an unnatural coldness of 
the surface, and there seems to have been no rise in tem- 
perature, but the thermometer in the rectum registers 104° 
F. or 105° F. 

Pulse. — The pulse in yellow fever is never accelerated in 
proportion to the rise in temperature. It rarely becomes 
as frequent as in other forms of continued fever, seldom 
reaching more than 110 beats per minute. In quite severe 
cases it may only reach 100, and in the milder cases it may 
not be accelerated more than five or six beats. It has a 
peculiar character ; many writers term it a " gaseous pulse." 
It is easily compressed and has an uncertain volume and 
character. This peculiarity of pulse is an element of differ- 
ential diagnosis. 



96 YELLOW FEVEK. 

Eye. — The eye is suffused, and the conjunctiva becomes 
congested quite early in the disease. The appearance of the 
countenance in severe cases has almost uniformly been 
regarded as diagnostic of this disease. The eyes are red 
and watery, and the conjunctivae are so intensely congested 
that the eyes resemble two balls of fire, while the face has a 
dusky, deathly hue ; these give to the countenance a re- 
markable expression of dejection and distress. 

Tongue. — The tongue is early covered with a thick white 
coating, except at its tip and edges, which are red, and in 
fatal cases, towards the close of life, sometimes the tongue 
becomes dry, brown, cracked, and fissured, resembling the 
tongue of typhoid fever. There is loss of appetite, and 
from the very onset of the disease there is more or less 
nausea and vomiting. 

Vomiting. — Nausea and vomiting may be regarded as 
among the most constant and characteristic symptoms of 
yellow fever. They come on soon after the chill, and con- 
tinue throughout the entire coarse of the fever. At first the 
matters vomited are simply the contents of the stomach, 
then they become yellowish or greenish in color, are fluid, 
and have an alkaline reaction. There is nothing about the 
matters vomited that is characteristic of yellow fever. If 
the vomiting subsides without any other changes in their 
character, it is quite evident that the case is going on to 
recovery. In the fatal cases the vomiting continues un- 
til a few hours previous to death, and in some cases until 
the hour of death. In a large proportion of these cases 
there is finally developed the striking and w^ell-known 
black vomit, which has been regarded as characteristic of 
this fever, and which by some is supposed to occur only in 
this disease. This peculiar vomiting may occur upon the 
second or third day of the fever, but more commonly it 
does not come on until thirty-six or forty-eight hours pre- 
vious to death, or not until the day of death. It undoubt- 
edly occurs more frequently in yellow fever than in any 
other disease, but it differs in none of its constituents 
from a similar material which is sometimes vomited in other 
diseases. A microscopical examination of the black vomit 



SYMPTOMS. 97 

shows it to consist of pigment matter in the form of fine 
grannies, aggregated non-grannlar masses, and globnles 
which resemble blood-globules. In addition to this color- 
ing matter there are found epithelial cells from the mucous 
membrane of the stomach, lymphoid cells or white globules 
which have undergone degeneration, and serous fluid. The 
pigment material is due to changes produced by the action 
of the gastric secretions upon the blood that has escaped 
from the walls of the vessels of the mucous membrane of 
the stomach into its cavity. The action of this gastric secre- 
tion upon the red blood-globules is such as to permit the 
escape of their coloring matter in the form of granules or 
small rounded masses. The same change will occur when- 
ever blood escapes in small quantities by a capillary hemor- 
rhage into the cavity of the stomach. Although this may 
occur in other diseases, yet when it does occur in yellow 
fever, it should be regarded as a grave symptom. The 
vomiting is projectile in character, and in this respect is 
peculiar to this fever. 

The bowels are usually constipated. If diarrhceal dis- 
charges are present, generally they are of a dark color, 
and frequently contain fluid blood, as there is the same ten- 
dency to capillary hemorrhage from the mucous membrane 
of the intestines as from the stomach. 

Urine. — The changes in the urine are regarded by some 
as diagnostic. Early in the disease it has an acid reaction. 
As soon as bile is present in the urine its reaction becomes 
alkaline. By some this alkalinity is regarded as an evidence 
of commencing convalescence, but there is no reason for 
such an opinion, for this change in the urine might be 
expected as soon as bile becomes one of its constituent 
parts, but it is not due to any peculiar action of the yellow 
fever poison. 

Albumen has been found in the urine in all fatal cases, 
and early in the attack, it has been found present in moder- 
ate quantity, in all severe cases, but as the disease progressed 
it became more or less abundant according to the severity 
of the fever. Entire suppression of urine is of frequent 
occurrence in severe cases, and no symptom, not even the 
7 



98 YELLOW FEVER. 

black vomit, is so unfavorable as the complete suppression of 
urine. A patient with black vomit does not necessarily 
die, but complete suppression of urine is almost invariably 
followed by a fatal termination. 

Under the head of the morbid anatomy of this disease 
were described the kidney lesions which account for the 
suppression of urine ; for if the kidney changes are exten- 
sive, it is impossible for these organs to perform their func- 
tion, and death is the necessary result, for acute ursemia is 
added to the fever poisoning. 

Delirium is rarely present, but when it occurs it is wild 
in character, and it is marked by a constant desire on the 
part of the patient to get away from some impending dan- 
ger. Usually the mind is clear, but a peculiar apathy takes 
possession of these patients, and they often lie in a state of 
complete collapse, with shrunken features, entirely indiffer- 
ent and unconcerned as to their condition. 

Jaundice. — The yellow color of the skin, which is so 
prominent and constant a symptom of yellow fever, usually 
does not appear until about the third day of the fever. It 
is first noticed about the eyes, but soon extends over the 
entire body. Some have maintained that this discoloration 
of the skin is a true jaundice, due to a retention and reab- 
sorption of bile, in the same manner as we have acute jaun- 
dice following an obstruction of the gall duct. Those who 
do not accept this doctrine maintain that the gall ducts are 
not found obstructed, hence there is no reason for the reten- 
tion and reabsorption of the bile. 

The true etiology of the jaundice in yellow fever may be 
stated as follows : the yellow fever poison is introduced 
into the circulation, and produces its specific changes in the 
blood ; that is, the red globules are destroyed within the 
circulation, the hsematine in them is changed into pigment 
matter, and a staining of the tissues of the body follows, 
which is a real hematogenous jaundice. 

Admitting these blood-changes to have taken place, we 
find a ready explanation of many other changes which take 
place in this disease. The blood-globules to a great extent 
are destroyed, and in consequence the blood loses its vital- 



SYMPTOMS. 99 

izing power. This induces defective nutrition, and leads to 
f'litty degeneration of the liver cells and the renal epithe- 
lium. The walls of the capillary vessels become enfeebled, 
to which is added the qualitative alterations in the blood 
itself, and these lead to hemorrhagic extravasations in vari- 
ous parts of the body which mark the progress of this dis- 
ease. 

It is of importance that you remember that in yellow 
fever, about the third or fourth day, sometimes within 
twenty-four hours from the commencement of the attack, 
the temperature rapidly falls, so that in twelve hours it 
may reach its normal standard. In the majority of in- 
stances it does not fall below 100° F., and there is no dis- 
tinct intermission,* but a decided remission. The pain in 
the head and back now subsides, the patient is in every 
way very much improved, and you may consider him con- 
valescing. Yet, in a day or two, there may be a return of 
all the febrile and other distressing symptoms which were 
present in the early period of the fever ; after these have 
continued for twenty-four or forty-eight hours, usually 
convalescence is established ; especially is this the case 
when recovery is to take place as soon as the remission is 
established. In such cases, with the remission, the pain in 
the epigastrium, the vomiting, and the yellow discoloration 
of the skin all begin to subside. The patient is now able to 
take nourishment, and with the occurrence of these symp- 
toms, if the surface has been dry, a slight moisture appears, 
and the patient soon passes into a state of convalescence. 

On the other hand, the vomiting may continue, and the 
black vomit appear ; the distress and burning in the epigas- 
trium may become more and more severe ; there is greater 
restlessness, tossing, and agitation ; the albumen in the 
urine is more abundant ; the urine becomes more and more 
scanty, until finally complete suppression occurs, and coma 
and death follow. 

Some epidemics are marked by a predominance of one 
class of symptoms and some by the predominance of an- 
other class, so that it is difficult to give a history of this 
fever which shall accord with all its different modes of de- 



100 YELLOW FEVER. 

velopment. Consequently, there have been many varieties 
of yellow fever described, such as the comatose, the algid, 
etc. Strictly speaking, these so-called varieties are simply 
variations in the clinical manifestation of the disease pro- 
duced by the degree of poisoning, and by some peculiarity 
in the atmospheric conditions under which it prevails. 

Some epidemics are much more fatal than others, and the 
ratio of mortality is much less during the latter part than 
during the early part of an epidemic. 

At the present time, there seems to be little question but 
that the immediate cause of death in all severe epidemics 
of yellow fever is due to uremia. The yellow fever first 
produces its changes in the blood, which leads to such 
glandular changes, especially of the kidneys, as arrest 
glandular functions, and a secondary blood-poisoning is 
the result. 

Some writers have described a period of collapse. It is 
true that a condition of collapse not unfrequently occurs, 
but it is nothing more than a period of commencing death. 

Differential Diagnosis. — Yellow fever has been con- 
founded with malarial fever, relapsing fever, and with acute 
atrophy of the liver. Under ordinary circumstances the 
diagnosis of yellow fever is not difficult, yet there are cer- 
tain types of malarial fever which are especially liable to 
be mistaken for it. 

Some writers have even gone so far as to maintain that 
the so-called bilious-remittent is only a modification of yel- 
low fever. At the present day, it has been fully established 
that each is a distinct type of fever. The following are the 
points of differential diagnosis between them : 

First. — The character of the prevailing disease, the re- 
gion in which it prevails, and the manner of its endemic or 
epidemic development. Yellow fever prevails in seaports, 
remittent fever in inland towns. Yellow fever is, remit- 
tent fever is not portable. 

Second. — The difference in the manner of invasion of the 
two diseases, the difference in the range of temperature, the 
projectile character of the vomiting in yellow fever, and its 
non-projectile character in remittent, the peculiar character 



DIEFEEENTIAL DIAGNOSIS. 101 

of pulse in yellow fever, as well as the almost characteris- 
tic expression of the countenance, is quite sufficient to dis- 
tinguish it even from the so-called yellow type of remittent 
fever. Then the difference in the anatomical changes, and 
in the effect of quinine in the two diseases is very striking. 
There is a yellow discoloration of the skin in both diseases, 
but it appears earlier and is more intense in yellow than in 
remittent fever. The presence of an enlarged spleen would 
lead to the diagnosis of remittent rather than yellow fever. 

Relapsing Fever. — At the first appearance of this dis- 
ease in a new locality it may be confounded with yellow 
fever. You will be led to a correct diagnosis by study- 
ing the etiological relations of the two diseases. Relaps- 
ing fever is, yellow fever is not, propagated by contagion. 
Then, the almost typical range of temperature in relapsing 
fever furnishes a marked distinction between it and yellow 
fever. In the former if yellow discoloration of the skin is 
developed, it does not come on until late, generally not 
until the relapse. An enlarged spleen is the rule in relaps- 
ing, and the exception in yellow fever. Hemorrhage from 
the mucous surfaces may occur in both these types of fever, 
and there can be little question but that the blood-changes 
are very similar in kind, but not in degree, in these two 
forms of fever. During the past two years, in the wards of 
Bellevue Hospital, in two instances, has acute yellow atro- 
phy of the liver been mistaken for yellow fever. If an 
accurate history of the cases could have been obtained, 
doubtless the mistake in diagnosis would not have been 
made. 

In yellow atrophy of the liver, as well as in yellow fever, 
there is jaundice with fever, and vomiting of a black mate- 
rial accompanied by suppression of urine ; but the history 
of the development of the two diseases and the gradual but 
steady diminution in the size of the liver in yellow atrophy, 
while in yellow fever the organ rather increases than dimin- 
ishes in size, is sufficient for a diagnosis. 

The difficulties which attend the differential diagnosis of 
yellow fever are often very great ; in fact, sometimes it is 
impossible to make a positive diagnosis. For example, some 



102 YELLOW FEVEK. 

of the crew of a ship coming from an infected port become 
jaundiced, have hemorrhage from the mucous surfaces, ac- 
companied by fever of a remittent type ; if these patients 
have previously suffered from intermittent fever, attended 
by an enlargement of the spleen, it will be almost impossible 
in the earlier cases to decide between so-called bilious-re- 
mittent and yellow fever. 

Prognosis. — The average duration of yellow fever is six 
days ; sometimes it destroys life in three days. The prog- 
nosis greatly varies in different epidemics. The highest 
recorded ratio of mortality which I have been able to find 
is one death in every three cases. 

Some writers have claimed that more than one-half the 
cases are fatal, but upon a careful examination of statistics 
I find they give no such percentage of death. In some 
epidemics the fever is of so mild a type that only a very 
few cases terminate fatally, perhaps one in fifteen or twenty. 

A consideration of the following conditions is of impor- 
tance in making our prognosis : 

The severity of the invasion of the fever. The intensity 
of the febrile excitement. The early appearance of the 
yellow tinge of the skin and the intensity of the jaundice. 
The greater the severity of the period of invasion, the 
higher the range of temperature ; the deeper the jaundice, 
and the greater the amount of albumen in the urine, the 
more unfavorable is the prognosis. If the quantity of albu- 
men diminishes, the patient is advancing toward recovery ; 
if it increases, a fatal termination is indicated. 

The elements of a favorable and unfavorable prognosis 
may be briefly stated. 

The favorable symptoms are a slow pulse, a slight rise in 
temperature, a quiet stomach. Streaks of blood during the 
latter stage of the fever are not regarded as indicating 
danger, especially if the blood-corpuscles are entire. Al- 
buminous urine without casts is not of serious import. 
Under all circumstances, a copious secretion of urine must 
be regarded as a favorable symptom. 

A recent residence in a temperate climate will enter very 
largely into the chances of recovery from yellow feyer. 



PROGNOSIS. 103 

The unfavorable symptoms are : a high temperature, a 
, red tongue, an irritable stomach, intense pain in the head, 
scanty urine, containing albumen and casts, black vomit, a 
faltering articulation, and difficulty in protruding the 
tongue. A streak of blood in the early vomit indicates 
great danger, especially if the blood -globules are broken 
down. The intensity of the jaundice, and the fact that the 
patient has recently suffered from an attack of yellow fever, 
render the prognosis unfavorable. 

In a large number of cases you will find great difficulty 
in giving a positive prognosis. The presence of the "black 
vomit" and an entire suppression of urine render a case 
almost hopeless, as has already been stated. Recovery 
after the occurrence of "black vomit" is more frequent 
than after suppression of urine. In mild and in severe 
cases the period of convalescence is in proportion to the 
duration of the disease. In some cases it is not fully 
established until two weeks after the cessation of the febrile 
symptoms. Complete recovery does not take place in some 
cases until five or six months after the commencement of 
convalescence. 

There are no certain sequelse of yellow fever. Cellulitis 
and abscesses are spoken of by some writers, but they are 
by no means constant. 

Treatment. — Before considering in detail the treatment 
of yellow fever, I would say a few words concerning its 
prophylaxis. The prophylactic measures for the most part 
are included under the general head of quarantine regula- 
tions. It is possible by strict quarantine to prevent the 
introduction of yellow fever into any district or seaport 
where it is not indigenous. It is not necessary that I should 
enter upon a discussion of those quarantine regulations 
which have been found most successful in preventing the 
introduction of this disease ; these come rather within the 
province of State medicine. If you find yourself in a re- 
gion visited by an epidemic of yellow fever, you may escape 
it by removing beyond the limits of the infected district. If 
you are compelled to remain within the limits where the 
epidemic is prevailing, avoid everything which is regarded 



104 YELLOW FEVER. 

as a predisposing cause of the disease. Under such circum- 
stances most observers regard the sulphate of quinine, taken 
daily in moderate doses, as a prophylactic agent. 

The details of the treatment to be employed when the 
disease has once established itself are very unsatisfactory ; 
perhaps there is no disease the treatment of which is more 
unsatisfactory. Medical men widely differ as to the most 
effectual means to be employed in controlling or mitigating 
the severity of the fever. Physicians in India, and Ameri- 
can physicians who have come in contact with this fever, 
treat it very differently. Within the past few years there 
has been a marked change in the views of American physi- 
cians in regard to its treatment. 

The remedial agents which have been most extensively 
used are mercurials, bleeding, stimulants, and quinine. It 
is very difficult to accurately estimate the relative value of 
these different agents, for this reason, there are certain 
forms of this fever in which- no treatment avails anything, 
the patient receives his death-blow at the very onset of the 
fever. On the other hand, there are forms of so mild a type 
that the patient is almost certain to recover. Hence the 
great uncertainty which attends any plan of treatment, and 
the unreliableness of statistics in regard to its effects. 
Under all plans of treatment there are many deaths and 
many recoveries. I have already alluded to the four leading 
plans of treatment which have been resorted to for the 
management of this fever, namely, the mercurial, the blood- 
letting, the stimulant, and quinine plan. The plan now 
most generally adopted is the expectant, or, as it is called 
by some, the diaphoretic. 

At one time blood-letting was very extensively practised 
in the treatment of yellow fever, one hundred and eighty 
ounces of blood have been drawn from the temporal artery 
at a single bleeding. The most experienced and intelligent 
physicians, with the largest opportunities for observation, 
have abandoned this plan of treatment, which fact is suf- 
ficient argument against it. The same is true of the mer- 
curial plan of treatment ; now mercury is only employed as 
a cathartic at the very commencement of the fever. 



TREATMENT. 105 

The stimulating plan of treatment has also fallen into dis- 
repute. It was found that the administration of stimulants 
during the active period of the fever was not followed by 
good results. 

Again, our most competent observers unhesitatingly de- 
clare that quinine has no controlling power over the fever. 

Let us pause a moment and consider what are the indica- 
tions as to treatment. 

The great danger in yellow fever is that the kidneys will 
fail to perform their function. 

What more sensible plan of treatment than that which 
contemplates relieving the kidneys from excessive work % 
Here is an opportunity for the use of diaphoretics, and a 
certain amount of cathartic medicine, not to use them to 
such an extent as to produce exhaustion, but so far as to 
afford as much relief as possible to the kidneys. 

At the commencement of the attack counter-irritation 
over the region of the kidneys is undoubtedly of great 
service. 

The plan of treatment now most generally recommended 
and adopted is, as soon as a patient is taken with yellow 
fever, in addition to the application of counter-irritants over 
the region of the kidneys, to administer ten grains of calomel 
combined with ten grains of quinine. Why the quinine is 
added to the calomel I do not know. Keep up a moderate 
diaphoresis. At the same time administer lime-water and 
milk, which is said to have greater control over the nausea 
and vomiting than any other means which have been em- 
ployed. 

It has been recommended that the surface should be 
bathed with some alkaline lotion, on the theory that alka- 
lines applied to the surface have a controlling influence 
over the vomiting. There are no reliable facts to sustain 
this theory. 

In severe cases, during the fever, there is usually nausea, 
great restlessness, with tossing and rolling of the head. In 
order to quiet this uneasiness and jactitation some have pro- 
posed the use of chlorodine, others the administration of 
chloroform, but all have protested against the use of opium, 



106 YELLOW FEVER. 

because of the kidney lesions, insisting that by the use of 
opium in any form we ran the risk of causing additional 
disturbance of the function of the kidneys. 

I regard this restlessness to a great extent as due to the 
effect produced upon the nerve centres by the urea in the 
circulation, and believe that all these nervous manifesta- 
tions can best be controlled by thp hypodermic use of the 
sulphate of morphine. 

Perhaps it may be worthy of mention that a physician 
living in the West Indies has recently quite successfully 
treated cases of yellow fever by administration of carbolic 
acid in doses of one and a half to two grains every two 
hours. It is claimed that the carbolic acid given in this 
way arrests the changes in the blood produced by the yel- 
low fever poison. I should question very much if carbolic 
acid has any such power. 

As the course of this fever is very rapid, it is of the utmost 
importance to sustain the vital powers as far as possible till 
the morbid processes come to an end. This is always diffi- 
cult on account of the great irritability of the stomach — but 
as soon as the stomach is in a condition to receive food, you 
must endeavor to improve the composition of the blood by 
a most nutritious diet, combined with wine, quinine, and 
iron. 



MALARIAL FEVERS. 



LECTURE X 



MALARIAL FEVERS. 

Introduction. 

When I began the history of fevers, you will remember 
that I divided them into three general classes, namely, the 
contagious, the malarial, and the miasmatic-contagious. 

This morning I commence the history of those which are 
included under the head of malarial fevers. I pursue this 
course for the reason that I believe you will be better pre- 
pared to study contagious fevers after you shall have 
become familiar with the malarial. The different varieties 
of malarial fever are like different branches of the same 
tree; they have, many things in common, yet differ from 
each other so widely in the phenomena which attend their 
development, that they may be regarded as distinct dis- 
eases. They have a common origin in a poison which has 
received the name of miasm. 

All varieties of these fevers depend upon one and the 
same poison, which is subject to certain variations in quan- 
tity. The concentration of this poison determines the 
severity and, to a certain extent, the type of the fever. It 
is possible to arrange the different types in a progressive 
scale, from the mildest to the most severe, beginning with 
the simple intermit tent and passing on to the most severe 
type of pernicious fever. The extent of the morbid pro- 
cesses, and the rapidity with which they are developed, 
depend upon the intensity of the malarial poison, the 
Length of time the individual has been under its influence, 



110 MALAEIAL FEVERS. 

and, to some extent, upon individual idiosyncrasies. Many 
theories have been advanced as to the nature of this miasm 
or malarial poison. By some it is regarded as gaseous in 
its nature ; others believe it to be a living vegetable organ- 
ism ; and, again, others think it is a specific poison, having 
no tangible, chemical, or microscopical constituents. 

No one of these theories, nor of the many others which 
at different times have been advanced, have been sustained 
either by facts or by reliable chemical or microscopical 
analysis. Thus far we have no positive knowledge in regard 
to its true nature, but we do know something of the cir- 
cumstances which are necessary for its production and the 
laws which regulate its development. 

First. — There must be a certain amount of vegetable 
matter, either on the surface or in the substance of the soil, 
where the malarial poison is generated. It is not necessary 
that the quantity be large, but a certain amount is a neces- 
sity. 

Second. — A certain amount of moisture must be on the 
surface or in the substance of the soil ; it need not be 
excessive ; but some is indispensable. 

Third. — A certain average degree of temperature is neces- 
sary for its production. It cannot be developed below an 
average temperature of 58° F. for the twenty-four hours, 
and will not prevail as an epidemic unless the average tem- 
perature ranges as high as 65° F. for the twenty-four hours. 

In regions where these fevers prevail, their type, form, 
and intensity, to a great degree, depend upon the height 
of the temperature. 

As a rule, malarial fevers are endemic, rarely extending 
over large sections of country in the form of an epidemic. 
I will repeat, three things are known to be necessary to the 
development of miasm or malarial poison, namely : the 
presence of decomposing organic matter, a certain amount 
of moisture, and a certain average range of temperature. 

We also have some knowledge concerning the regions in 
which malarial fevers are most likely to prevail, and which 
seem most favorable to the development of malarial poison. 

First. — Marshes are especially favorable to the develop 



IE-TKODUCTION. Ill 

ment of this poison, and may generate it for an indefi- 
nite period. The Pontine marshes have been malarial for 
more than two thousand years. Yet all marshes are not 
malarial ; their power to generate the malarial poison varies 
with the amount of water they contain. Where there is an 
abundance of water, malarial fevers are rare ; when they 
are covered only by a thin sheet of water, and are exposed 
to the direct rays of the sun, malarial poison will abound. 
Marshes that have dried up are especially favorable to 
the development of this poison, yet as soon as heavy rains 
submerge the previously parched surface, the power to 
generate the poison is for a time diminished or entirely 
arrested. 

Scattered here and there over onr own continent are 
districts which have been malarial ever since the white man 
has held possession of them ; whether such was the case in 
earlier times, our history is too uncertain for us to de- 
termine. 

As a rule, salt-water marshes are especially free from 
malaria, but when salt and fresh water become mixed in 
the marsh, as, for instance, on the New Jersey fiats, you 
have the most favorable conditions of marsh for its abun- 
dant development. Those marshes resting on a substratum 
of sand are far less malarial than those resting on lime- 
stone, clay, or mud. 

There are marshes in the higher latitude of our own and 
other States which often, during the heat of summer, be- 
come dry, yet no malarial poison is generated (although 
during the day the thermometer may reach 90° F.) ; for 
this reason, that during the night the atmospheric temper- 
ature falls below 50° F. 

There are some quite extensive marshes in which appar- 
ently every condition for the development of malaria exists, 
and yet none is generated. We cannot account for this 
fact, unless we accept the theory that the ozone which is 
claimed to be present in such marshes arrests or prevents 
its generation. 

"Damp bottom-lands" that are exposed to an annual 
overflow, such as are found along the southern shores of 



112 MALAEIAL FEVERS. 

the Mississippi River, are as fruitful as swampy regions in 
the generation of this poison. 

Second. — Another condition which seems to favor the 
development of malaria is the upheaval of new alluvial 
soils, such as obtain when new lands are first brought 
under cultivation. This same state of things also occurs 
throughout the middle and southern portions of this State, 
and in the ISTew England States. 

Where railroad excavations are made, malarial fever is 
very frequently developed. 

In this city, while the so-called " Fourth avenue im- 
provements" were being made, the entire region along 
the avenue was rendered highly malarious by the excava- 
tions. Such excavations bring decomposing vegetable 
matters to the surface ; these, under the influence of heat 
and moisture, generate miasm. 

The fact that fevers of this type appear in regions pre- 
viously free from them, as soon as these conditions favor- 
able to their development exist, is confirmed by the testi- 
mony of many careful observers. 

Third. — Regions otherwise non-malarial may have ma- 
larial poison brought to them by the waters of rivers which 
have their source in, or flow through, malarial districts. 

Examples of this kind are found along the banks of our 
Western rivers, where are developed some of the most per- 
nicious types of this fever ; while in places only a short 
distance from these rivers it is unknown. 

This can be accounted for, if we accept the theory that 
malarial poison has been transmitted through waters having 
their source in, or running through, malarial districts. 

Fourth. — Non-malarial regions may be rendered malarial 
from poison transmitted by the wind. 

There has been considerable discussion as to whether this 
poison can be transmitted in such a manner, and if it can 
be, to what distance. I find no reliable account of its trans- 
mission over a greater distance than four and three-quarter 
miles. 

Malarial fever broke out in the crew of a ship, which was 
anchored just four and three-quarter miles from shore where 



INTRODUCTION. 113 

this fever was prevailing. ISTo cases were on board when the 
anchor was cast, nor did any of the crew go on shore. So 
long as the wind blew from the ship towards shore, the 
crew remained well, but when the wind changed its direc- 
tion and blew from the shore towards the ship, within six 
days from the time of change, cases of well-developed 
malarial fever appeared on board. This seemed to prove 
conclusively that the fever was brought to the ship by the 
wind. 

The wind may also carry malarial poison up along the 
sides of mountains, to an elevation of one thousand feet ; 
some writers say no higher than six hundred feet. 

American writers give no account of its being carried 
higher than six hundred feet, while some German writers 
give well authenticated cases, which show that it must have 
been carried to the height of one thousand feet. 

I have thus far called your attention to some of the more 
important conditions which are necessary to, or seem to 
favor, the development of this malarial poison. You have 
seen that certain of these conditions are absolutely neces- 
sary for its production. I have also noticed most of the 
conditions which render its development more active. 

I will now briefly consider some of the circumstances 
which are inimical to its production. 

First. — Higli latitude. In this country malarial poison 
is not generated in higher latitude than that of Quebec. 
The limit of its development is 63° north latitude, and 57° 
south latitude. Between these two parallels of latitude, 
both on the eastern and western hemispheres, malarial 
fevers may be developed ; the nearer the approach to the 
equator, the more severe the type. They do not prevail 
over the entire region embraced between these parallels of 
latitude, but it is possible for them to be developed at any 
point where the altitude is not too great. 

Second. — High elevation is another condition inimical to 
its development. As a rule (as I have already stated), it is 
not generated above an elevation of one thousand feet above 
sea level. 

There are, however, some remarkable exceptions to this 
8 



114 MALARIAL FEVERS. 

rule. We find recorded cases of malarial fever which have 
been developed upon plateaus among the Pyrenees, at an 
altitude of 5,000 feet. I have already referred to the fact 
that malarial poison is much more readily developed in 
marshes which have a clay or lime-stone bottom, than in 
those which have a sandy or porous substratum. Among 
the Pyrenees, there is a marsh which has a clay bottom, 
and there malarial poison is developed which is very per- 
sistent. 

Third. — Drainage is another means which diminishes, 
and in certain conformations of soil entirely destroys mala- 
rial generation. In the majority of marshes, this generation 
can be arrested or prevented by free drainage. Yet there 
are marshes upon which millions have been expended in 
drainage, which still remain pestiferous. 

Perhaps it is possible to drain the Jersey flats so as to 
render them non-malarial in their character, but it is hardly 
probable that this change can be effected, for they have a clay 
bottom, and contain both salt and fresh water, conditions 
which I have stated are most favorable to malarial genera- 
tion. Years of labor and large expenditures of money have 
been bestowed upon the Pontine marshes to render them 
non-malarial, yet they are as pestiferous as they were two 
thousand years ago. 

Fourth. — Cold is a powerful agent in arresting malarial 
generation. I care not how pestiferous a region may have 
been, if only for one night the temperature fall below 
the freezing point, nothing more need be feared in that 
region from malaria, until the average temperature shall 
have again reached 60° F. This law holds in all malarial 
districts. In these districts, after the temperature has fallen 
below the freezing point, persons may have the fever, but it 
is the result of previous poisoning. 

Again, the generation is less rapid and the poison is less 
virulent during the day than at night. This is the uniform 
testimony of those who have seen most of, and written 
most on malarial diseases. It is also almost universally 
conceded that malarial districts are most pestiferous during 
months when the atmosphere is hot and dry, with little or 



INTRODUCTION. 115 

no wind, especially when this state of atmosphere lias been 
preceded by long, heavy rains, and that the virulence of the 
poison is greatly diminished as soon as fresh, strong winds 
clear the atmosphere. 

I have called your attention to the most prominent laws 
which seem to govern the production of this poison, as also 
I have endeavored to bring before you those conditions 
which favor, as well as those which hinder or prevent its 
development. The question now arises, How does malarial 
poison gain entrance into the human body ? 

The most reasonable view is that this is effected through 
the respired air. Certain facts seem to show that it may 
be introduced through the intestinal tract with the food 
and water. There seems to be scarcely a doubt but that 
it may be taken into the stomach with foul drinking-water. 
Accepting this view, in certain localities it has come to be 
the practice to add whiskey to the drinking-water to de- 
stroy the poison, but there is no reason for the belief that 
whiskey has any such power. 

When this poison has once been introduced into the cir- 
culation, it undoubtedly has the power of reproducing it- 
self, hence the entire system is affected. From this fact, 
which must be regarded as well established, those who 
regard this poison as a living organism, claim that these 
organisms may reproduce themselves indefinitely, but their 
existence has never yet been demonstrated. It has also 
been claimed that certain races are more exempt than others 
from malarial fever, also that there are idiosyncrasies of 
constitution which render certain individuals exempt from 
diseases of this type, for in districts where these fevers pre- 
vail there are persons who never have the fever. 

It seems to me that this exemption, both in races and 
individuals, is due to the greater physical power of the 
individual, which enables him to resist these noxious atmo- 
spheric influences. 

In a district where malarial influences prevail, the weak 
and anaemic are the most liable to be attacked, and all those 
influences which tend to lower vitality, and to render feeble 
the powers of resistance, must be regarded as special predis- 



116 MALARIAL FEVERS. 

posing causes. A strong man may resist for a long time, 
while the old man and the child very quickly succumb to 
the influence of the poison. Women are more suscep- 
tible than men to its influence. You can no more account 
for the fact that one person can take in large doses of mala- 
rial poison without being effected by it, while another is 
affected by a very small quantity, than you can account 
for the fact that one individual can take large quantities of 
alcoholic stimulants without showing any signs of intoxica- 
tion, while a very small quantity will intoxicate another 
individual, supposing, in both instances, the individuals to 
have apparently an equally vigorous constitution. 

Some claim that when an individual has been poisoned 
with malaria, complete recovery never takes place ; others 
claim that even with the w r orst cases recovery is possible. My 
own experience leads me to believe that when an individual 
has once suffered from malarial poisoning, he is much more 
susceptible than one who has never been so poisoned. For 
instance, an individual suffers from one or more attacks of 
intermittent fever, and then removes from a malarial dis- 
trict, if that person again enters a malarial region, he is 
much more likely to suffer from malarial fever, however 
slight the poisoning may be, than if he had never suffered 
from its effects. Some unknown physical change has taken 
place which renders him a fit subject for malarial manifesta- 
tions upon the slightest exposure. - 

This brings us to the doctrine of the latency of malarial 
poison in the human body. This is an interesting and at 
the same time a very obscure subject. 

That there is a period of incubation, or rather that a cer- 
tain time elapses between the exposure and the develop- 
ment of malarial fever, seems to be a settled question. For, 
often a long, always a short period elapses before new- 
comers in malarial districts have their first attack of the 
fever ; sometimes the poison remains latent until after they 
have removed from the district. It is on this basis, the 
latency of the malarial poison, that the relapses can be 
accounted for, which occur in those who, having lived in a 
malarial district, remove and remain in a non-malarial one„ 



INTRODUCTION. 117 

This reawakening of the malarial poison may depend npon 
a variety of causes, such as taking cold, over-fatigue, sud- 
den changes of temperature, etc., etc. 

Whether an individual who has once been thoroughly 
poisoned with malaria can ever become entirely free from 
its influence, is still an unsettled question. 

From my own observation, I am convinced that it is im- 
possible to bring one wholly from under the influence of the 
poison while he remains in a malarial district, though he 
may become exempt from its influence (without the re- 
awakening causes already mentioned, taking cold, etc., etc.), 
if he remains beyond the malarial belt. 

Undoubtedly, you have often heard it stated that an 
individual may become so acclimated as to resist malarial 
influences, and live for a long time in a malarial district 
without suffering any evil effects from it. 

There can be no question but that those living in such 
districts suffer less from the acute manifestations of the 
poisoning than do new-comers. But the truth is, those 
changes, which we call chronic malarial affections, are 
constantly going on in those who are supposed to be 
acclimated. 

The comparison still holds good in reference to those 
addicted to the use of alcohol. We might say, they are 
becoming acclimated to its use. The first dose a person 
takes may make him drunk, but after a time repeated and 
larger doses fail to produce this effect. Malaria acts like 
any other poison : after a time the system reaches a certain 
degree of tolerance. 

This tolerance of malaria, or immunity from its manifes- 
tations, amounts to nothing more than the accommodation 
of the system to its prevailing influence. 

Let the acclimated person, as he is called, be taken sick 
with any active form of disease, such as diphtheria or 
pneumonia, and it usually proves fatal, not that there is 
anything unusually severe in the diphtheria or pneu- 
monia which brings about the fatal termination, but death 
is due to the fact that the system is charged with malarial 
poison. 



118 MALARIAL FEVERS. 

There is another point in this connection concerning which 
I wish to say a few words. 

It has been claimed by very intelligent and careful ob- 
servers that phthisical developments are prevented by 
malarial poisoning. After having carefully investigated 
this subject, I am convinced that the effect of the poison on 
the human organization is to predispose it to phthisical 
developments. The milder climate and the less frequent 
changes in temperature in the malarial regions accounts 
for the fact that there is less phthisis in those regions than 
in the cold, non-malarial regions. The malarial districts 
in the northern portion of the temperate zone have the 
highest death rate from phthisis. If we accept the fact 
that the larger number of cases of phthisis are catarrhal in 
their origin, and that catarrhal pneumonia is more likely to 
be developed in those who are broken down from the pro- 
longed influence of malarial poisoning, you will be prepared 
to understand how chronic malarial poisoning predisposes 
to phthisis. In quite a number of instances I have traced 
the beginning of phthisical development to this cause. 

There are many other points of interest closely connected 
with this subject of malarial poisoning, but which have no 
special connection with the class of diseases which we are 
about to study. 



LECTUEE XI 



SIMPLE INTERMITTENT FEVER. 

Morbid Anatomy. — Etiology. — Symptoms . — Differential 
Diagnos is. — Prognosis. — Treatment. 

I have spoken of the origin of malarial fever, and of cer- 
tain known facts concerning the development of the mala- 
rial poison, and to-day will commence the history of this 
class of fevers. First in order is simple intermittent fever. 

Like typhoid fever, simple intermittent fever is met with 
in all parts of the world, although the region of its develop- 
ment may be said to be limited by 63° north latitude and 
57° south latitude. Within these parallels it is the more 
prevalent the nearer you approach the equator. 

Morbid Anatomy. — The anatomical changes which take 
place in this fever are few and require only a passing notice. 
In regard to the blood-changes we are without any reliable 
chemical or microscopical data. We find none of those 
changes in the blood which are present in the more severe 
forms of infectious disease, neither do we find those which 
are present in the pernicious type of malarial fever, such as 
pigmentation and marked diminution in the red globules. 
If the fever has continued for a long time there may be 
slight diminution in the number of the red globules and a 
decrease in the fibrin of the blood ; but these changes, to a 
great extent, are due to the high temperature which attends 
its paroxysms. The only constant pathological lesion of 
simple intermittent fever is congestion of the internal or- 
gans. The spleen and liver are always more or less en- 



120 SIMPLE INTERMITTENT FEVER. 

larged, but the enlargement is due to simple hypersemia ; 
no structural changes occur in these organs until the inter- 
mittent paroxysms have been often repeated, and the mala- 
rial poisoning has been of long duration. There is also 
more or less hypersemia of the kidneys and the mucous 
membrane of the intestines, but it is not attended by any 
signs of gastric or intestinal catarrh. As yet no one has 
been able to prove that any structural change takes place 
either in the nerve tissue or in any other tissue of the body ; 
nor from the structural or functional disturbances that oc- 
cur during the fever, has any one been able to find a satis- 
factory answer to the question, why it is a paroxysmal and 
not a continued fever ? By some German writers it is 
claimed that during a paroxysm of the fever white blood- 
globules are very rapidly developed ; but the question arises, 
how is this to be demonstrated ? I have never seen a post- 
mortem examination on one who had died during a simple 
intermittent paroxysm, and have never heard of such a 
death unless the patient had some intercurrent disease. As 
I have already stated, all the appreciable lesions of simple 
intermittent are those of hypersemia. 

Etiology. — At my last lecture this subject was brought 
to your notice. All agree that simple intermittent fever is 
due to malarial poisoning, and that the poison is introduced 
into the body either through the lungs or through the in- 
testinal tract. 

Whatever tends to depress the mental or physical powers 
of an individual renders him more susceptible to malarial 
influences, and consequently these depressing influences 
must be regarded as predisposing causes. Among these 
may be included intemperance, exposure to night air, exces- 
sive fatigue, bad hygiene, and a long list of like debilitating 
causes. - 

Symptoms. — This fever is a paroxysmal disease, of differ- 
ent types, according to the period of time between the par- 
oxysms. 

The first, and most common, is the quotidian type, in 
which the paroxysm occurs every day, and there is an in- 
terval of twenty-four hours between the paroxysms. 



SYMPTOMS. 121 

Second, you have the tertian type, in which the parox- 
ysm occurs every third day, with an interval of forty-eight 
hours between the paroxysms. 

Third, you have the quartan type, in which the parox- 
ysm occurs every fourth day, with an interval of three days 
or seventy-two hours between the paroxysms. 

These are the regular and more common types of inter- 
mittent fever. Medical writers make mention of other 
types, which, although irregular, are unquestionably modi- 
fications of those already mentioned. Among these is what 
is described as double quotidian, in which two paroxysms 
occur daily. Usually one paroxysm is severe, the other 
mild ; the severer one generally occurs in the morning, the 
milder in the afternoon or evening. There is also a double 
tertian, in which a paroxysm occurs daily, but it differs 
from the quotidian, as the paroxysms that resemble each 
other occur at intervals of forty-eight hours. For instance, 
the paroxysm of to-day is characterized by the occurrence 
of a severe chill and mild fever ; to-morrow it is character- 
ized by a short chill and severe fever; the following day 
there occurs the severe chill and mild fever, as on the first 
day. 

Some writers describe a form of intermittent fever in 
which the paroxysm occurs on the seventh, fourteenth, 
twenty-first day, etc., with an interval of seven days be- 
tween the paroxysms. 

The types most frequently met with are the quotidian, 
tertian, and quartan. 

In the quotidian variety the paroxysm occurs in the 
morning, in the tertian it occurs about noon, while in the 
quartan it occurs in the afternoon or evening. The dura- 
tion of the paroxysm varies with the type of the fever. In 
the quotidian it lasts from eight to ten hours, in the tertian 
it lasts from six to eight honrs, in the quartan from four to 
six hours. 

There are many exceptions to these rules, but it is a 
question whether we would have them if the disease was 
permitted to run its course without treatment. 

Paroxysms. — A paroxysm of intermittent fever has three 



122 SIMPLE INTERMITTENT FEVER. 

stages, namely, the cold stage, the hot stage, and the stage- 
of sweating. In most cases these are easily distinguished 
the one from the other. 

In the true type of intermittent fever we have regular in- 
tervals between the paroxysms of fever. 

Let us notice some of the phenomena which attend one 
of these paroxysms. 

After the patient has suffered for a certain length of time 
with pain in the head, a sense of languor, and some nausea, 
he passes into the cold stage. 
/ Cold Stage. — His passage into this stage is first marked 
by a sensation of coldness along the back, which soon extends 
to the extremities, and an uncomfortable sensation of cold- 
ness gradually creeps over the entire body. The skin be- 
comes shrivelled, the finger ends and lips become blue, the 
face is pale, the eyes are sunken, chills rapidly follow each 
other, the teeth begin to chatter, any voluntary motion is 
attended by trembling, until finally, as one chill after an- 
other in quick succession passes over the body, the patient's 
teeth chatter so that it can be heard some distance from the 
patient, and there is a shaking of the entire body. 

The surface of the bod}^ becomes rough, the blood seems 
to recede from it, and the skin assumes the appearance 
described as goose-sldn or cutis anserina. The temperature 
of the surface of the body is lower than normal, but if you 
place the thermometer in the axilla or under the tongue 
you will find that the temperature has reached 104° F. or 
105° F. The voice of the patient is weak and husky, the 
respirations are rapid, short, and sighing, but the mind re- 
mains clear. The urine is increased in quantity, and paler 
than normal, and there is frequent desire to empty the blad- 
der. Usually these symptoms are present from half an 
hour to two or three hours ; the length of time depends 
upon the severity of the case. 

After the cold stage has continued for a longer or shorter 
period, the patient begins to have flashes of heat alternating 
with the chilly sensations. Usually these are first felt at 
the extremities, but they rapidly extend over the whole 
body, and the hot stage is established. v - 



SYMPTOMS. 123 

/ Hot Stage. — The skin, in this stage, is no longer shriv- 
elled, but becomes red, swollen, and turgid, and there is a 
recession of the blood from the central organs to the sur- 
face of the body. That the temperature is elevated can be 
ascertained simply by laying the hand upon the surface. If, 
however, you place the thermometer in the axilla, in most 
cases you will find the temperature has reached 106° or 107° 
F. The thirst is very much increased. The comfortable 
sensation which the patient experienced while passing from 
the cold to the hot stage has given way to great restlessness 
and uneasiness, the patient tossing from side to side, with 
face flushed, and eyes red and fiery. Sometimes herpetic 
vesicles appear about the mouth. The heat and thirst be- 
come intense, the tongue becomes dry, the carotids pulsate, 
the radial pulse becomes firmer and more rapid than in the 
cold stage, and nausea is now a marked symptom. It may 
have been present in the cold stage, but in the hot stage 
nausea and vomiting become the prominent symptoms. As 
a rule the symptoms of this stage last from half an hour to 
two hours. In exceptional cases they may continue for a 
much longer time. As I have already stated, the ordinary 
duration of a paroxysm of a quotidian intermittent is from 
eight to ten hours ; that of a tertian, from six to eight 
hours ; and that of a quartan, from four to six hours. It is 
possible, especially in those forms of malarial fever in 
which the poisoning is intense, for the hot stage of a quo- 
tidian to continue twelve hours. There is no condition in 
which, for the time, you have more intense fever than in the 
hot stage of intermittent fever. The urine, which, during 
the cold stage, was abundant and of pale color, now be- 
comes highly colored and scanty. Not unfrequently it is 
almost suppressed during the hot stage. Complete sup- 
pression of urine occurs only in the pernicious type of the 
disease. When the fever has continued for a longer or 
shorter time, a slight moisture appears upon the forehead 
which gradually spreads over the entire body, and the pa- 
tient becomes bathed in a profuse perspiration. He is now 
in the sweating stage. 
/ Sweating Stage. — As this stage comes on the former 



124 SIMPLE INTERMITTENT FEVER. 

restlessness and uneasiness passes away, and a feeling of 
comfort comes to the patient as the perspiration makes its 
appearance. The temperature rapidly falls ; the pulse rap- 
idly diminishes in frequency and force ; the pulsation of 
the carotids ceases ; the face assumes its normal appear- 
ance ; the congestion of the conjunctiva disappears ; and 
the patient rapidly passes from a high state of fever into 
one in which he falls asleep, and awakens after a period 
ranging from one to three hours, with a sense of exhaustion. 
y Interval. — During the interval between the paroxysms at 
first the patient may feel perfectly well, but if there is a 
frequent repetition of the paroxysms, there will very soon 
be a marked loss of vitality ; he becomes pale and feeble, 
and all the symptoms of malarial cachexia are present. 
There will be more or less of a jaundiced hue to the skin, 
enlargement of the spleen and liver, and pigmentation of 
the tissues. It is true that many paroxysms of simple in- 
termittent may occur before any such general disturbance 
of the health of the patient manifests itself ; yet, in the in- 
terval between the paroxysms, we cannot call the patient's 
condition one of perfect health. 

Usually, in the quotidian type, the day previous to the 
development of the first paroxysm, unnoticed by the pa- 
tient, there is a slight rise in temperature, perhaps from 
99i° F. to 103° F. At the same time he experiences a sense 
of lassitude, and is disinclined to make any exertion, either 
mental or physical. The temperature commences to rise 
in the morning, and by noon it has reached its maximum 
height ; then it begins to fall, and by evening it may have 
fallen to nearly its normal standard. Thus the course of 
the temperature is quite characteristic, and may be summed 
up as a rapid ascent, a short and intense stationary period, 
and critical defervescences constituting the paroxysms, with 
a perfectly normal temperature in the interval. The fol- 
loAving day another rise in temperature will be noticed ; 
now the rise does not occur in the morning, but after mid- 
day, perhaps so late as in the evening. Usually in the 
quotidian type of intermittent fever the highest tempera- 
ture is reached a little earlier each day ; if it is reached a 



DIFFERENTIAL DIAGNOSIS. 125 

little later, you may be certain that the fever is being mod- 
ified or controlled by treatment. We have what are called 
anticipating and postponing paroxysms. When the par- 
oxysm comes on a little earlier each day, it is called 
anticipating, and indicates that the fever is not being 
controlled ; when it comes on at a later hour each day in 
indicates the fever is being controlled, and is called a post- 
poning intermittent. 

The types of intermittent fever which occur most fre- 
quently in temperate climates are the quotidian and the 
tertian. With us the quotidian is most frequent. In those 
who have suffered repeatedly from intermittent fever, the 
disease is liable to run an irregular course, the paroxysms 
occurring on irregular days, and with irregular intervals. 
In children this fever shows certain deviations from the 
ordinary course. The paroxysms may be ushered in by 
convulsions, or by a period of stupor. Children rarely have 
the distinct chill. After a period varying from ten minutes 
to half an hour, we have the hot stage of regular intermit- 
tent fever coming on, with all its attendant phenomena. 
The intermissions are rarely complete. The child loses his 
appetite and flesh, becomes irritable, and has a pale, waxen 
look, and surfers from gastric and intestinal disturbances, 
and the intermittent very soon lapses into a remittent. 

Differential Diagnosis. — The differential diagnosis of 
simple intermittent fever is never very difficult. There are 
only two diseases which are liable to be mistaken for it, 
namely, remittent fever and pyaemia. It is readily dis- 
tinguished from remittent fever, for in remittent fever there 
is never a complete intermission, whereas in intermittent 
there is always a period in which there is no fever. A care- 
ful thermometrical observation for twenty-four hours settles 
all question in regard to it. In remittent, the temperature, 
when at its lowest point during the remission, is one or two 
degrees higher than normal, while in intermittent the tem- 
perature reaches the normal standard during the intermis- 
sion. 

There is also a regular development of the paroxysm in 
intermittent, which does not occur in remittent. In remit- 



126 SIMPLE INTERMITTENT EEVER. 

tent usually you have but one chill, while in intermittent a 
chill precedes each paroxysm of fever. 

The diagnosis between intermittent fever and pyaemia is 
also readily established. In pyaemia, there is no complete 
Intermission in the fever and no regularity in the time of its 
occurrence, or in the severity of the paroxysms. In both 
diseases you have chills, fever, and sweats, but in pyaemia 
the chill is short ; rapid shivering is followed by a prolonged 
and very high fever, and this is followed by profuse sweat- 
ing. The sweating of intermittent is never so profuse as that 
of pyaemia, and in the latter disease there is no regularity in 
the development of the phenomena, while in intermittent, 
the nature of the paroxysms, and the time of their occur- 
rence, can be predicted with great certainty. The principal 
element in the clinical history of pyaemia is a steady, high 
temperature, without any intermission. When the sweat- 
ing comes on the temperature may fall one or two degrees, 
but it never approaches the normal standard, and there is 
never a distinct intermission. 

It is much more difficult to make a differential diagnosis 
between pyaemia and remittent fever than between pyaemia 
and intermittent. Hereafter this will be more fully con- 
sidered. The same thing may be said in regard to the 
hectic fever of phthisis. 

Prognosis. — The prognosis in simple intermittent fever 
is good. If continued for only a short time, there will be no 
tissue changes to prejudice the life of the patient. 

The possibility of the development of malarial cachexia 
must enter into the prognosis. When this occurs the case 
is more than one of simple intermittent fever ; there is en- 
larged spleen, enlarged liver, and pigmentation of tissues. 

Treatment.— The treatment of intermittent fever is di- 
vided into that for the paroxysm and that for the interval. 
The treatment for the paroxysm, in most cases, is simply to 
render the patient as comfortable as possible while passing 
through its various stages. At one time it was proposed to 
tourniquet the limbs, so as to prevent congestion of internal 
organs, and thus arrest the paroxysms. 

Again, it has been proposed to apply cold to the surface 



TREATMENT. 127 

of the body, for the purpose of giving a shock to the ner- 1 
vous system, and in that manner to arrest the paroxysm. 
To accomplish this, by covering the surface of the body 
with sinapisms, in order to irritate the cutaneous surface, 
has also been proposed. Some have claimed that if an in- 
dividual is brought fully under the influence of alcohol the 
regular development of a paroxysm can be prevented. 
Again, it has been claimed that opium, given in full doses 
at the usual time for the recurrence of the paroxysm, has 
power to prevent it. 

Experience does not lead me to accept any of these state- 
ments. It is true that, in some instances, a sudden shock to 
the nervous system may prevent the development of an 
intermittent paroxysm when the paroxysms have become a 
habit. 

If there is anything in the entire list of means (either re- 
medial or hygienic), that I have named, which has power 
to prevent the full development of a paroxysm, it is opium. 
When this is administered hypodermically, early in the 
cold stage, it will diminish the severity of the cold and hot 
stages. Whether, in the treatment of the milder forms of 
intermittent fever, the combination of opium with quinine 
is advisable, is still an unanswered question, though it seems 
to me that in such cases much comfort can be afforded, and 
the patient be much less injuriously affected by the parox- 
ysm, if opium be administered in moderate doses. 

Patients with intermittent fever should be kept in bed 
during the entire paroxysm, however mild it may be. 
During the cold stage, cover them with blankets, surround 
them with bottles of hot water, and let them drink freely of 
hot water. All these means will hasten the hot stage of the 
disease. During the hot stage, the extra clothing and ex- 
ternal heat should be gradually removed, and cold instead 
of hot drinks should be administered. If nausea and vomit- 
ing are present in this stage, you will find that opium, ad- 
ministered hypodermically, affords great relief. 

When the patient reaches the sweating stage, let him 
alone ; within a few hours he will be entirely relieved, and 
in a state of convalescence. The question now arises, What 



128 SIMPLE INTERMITTENT FEVER. 

treatment shall we adopt during the interval to prevent the 
occurrence of another paroxysm ? If possible to prevent it, 
never allow a patient to have a second intermittent par- 
oxysm ; for if the system once becomes accustomed to these 
paroxysms, they will be repeated upon the slightest provo- 
cation. You will frequently find this to be the case with 
persons who for a long time have not been subjected to 
malarial influence, and yet upon the least nervous excite- 
ment or fatigue will have a paroxysm. 

Let me impress upon you to prevent, if possible, the 
occurrence of a second paroxysm of intermittent fever. 

The great remedy at this time is the sulphate of quinine. 
Skilfully used, it is all-powerful to accomplish this result. 
How and why it arrests the development of these parox- 
ysms I do not know. We simply know the fact. Our 
knowledge of its antiperiodic power is purely empirical. 
There is much difference of opinion as to the mode in which 
it should be administered. In commencing the treatment of 
a case of intermittent fever, after the occurrence of the first 
paroxysm it is always safe to assume that the fever is of the 
quotidian type. At least thirty grains of quinine should be 
administered between the termination of the one paroxysm 
and the hour when another is to be expected. The first dose 
of ten grains should be given towards the close of the sweat- 
ing stage, and twenty grains about two hours before the 
time of the expected paroxysm. If possible, give the qui- 
nine in solution. If there should be sufficient irritability 
of the stomach to cause the rejection of the quinine, it may 
be administered Irvpodermically, or by enema. Three grains 
administered hypodermically has about the same antiperi- 
odic power as ten grains administered by the stomach. If 
you succeed in preventing the occurrence of a second par- 
oxysm you have accomplished much for your patient. 

Having prevented the occurrence of a second paroxysm, 
it is important that a moderate degree of cinchonism should 
be maintained for a number of days, by the daily adminis- 
tration of quinine in moderate doses. About two hours 
before the time of day at which the first paroxysm occurred, 
from ten to fifteen grains of quinine should be daily admin- 



TREATMENT. 129 

istered. You must not now permit your patient to pass en- 
tirely from under your observation. Direct him to visit you 
one month from the date of the first paroxysm, for, although 
he may not have had a fresh malarial exposure, there will be 
a strong tendency at this time to a repetition of the parox- 
ysm, and it is of importance that your patient at that time 
should be again brought fully under the influence of the 
quinine. If it is possible for your patient to remove from a 
malarial district you will be almost certain to prevent a 
second paroxysm. 

If, however, you do not see your patient in his first par- 
oxysm, and he lives in a malarial district, sulphate of qui- 
nine, administered in the manner I have just recommended, 
may only prevent for a time the return of the paroxysm, 
and even complete cinchonism may fail to control it. You 
should now very carefully examine the case, in order to as- 
certain if there is not some condition present which inter- 
feres with the antiperiodic action of the quinine, such as 
hepatic or splenic hypersemia. When careful percussion 
shows that the liver and spleen are increased in size, even 
after the administration of full doses of quinine, you will 
often find that the administration of full doses of calomel 
with the quinine will increase the antiperiodic power of 
the latter, and thus diminish the percussion area of these 
organs. 

Occasionally, when full doses of quinine combined with 
calomel have failed to prevent a recurrence of a paroxysm, 
I have noticed an unusual excitement attending its devel- 
opment, and believing from this circumstance that, owing to 
individual idiosyncrasies, the malarial poison had a more 
than usual irritating effect upon the nervous system, I 
have accomplished the desired result by administering full 
doses of opium with the quinine. In fact, if the patient 
is of a highly sensitive, nervous organization, I never allow 
a second paroxysm to pass without administering a full 
dose of opium before the time when its return is to be ex- 
pected. In all those cases which are called obstinate, ascer- 
tain why you have failed to control the disease by the use 
of quinine. 



130 SIMPLE INTERMITTENT FEVER. 

I rarely have administered arsenic in simple intermittent 
fever. If I fail to control the fever with quinine, after I 
have reduced splenic and hepatic congestion, controlled 
nervous irritability, and increased nutrition by the adminis- 
tration of iron and the moderate use of stimulants, I never 
succeed with arsenic. In some of the chronic forms of mala- 
rial manifestation, I have found arsenic of great service, 
but never in simple intermittent fever. 

Other means employed in the treatment of this fever will 
be spoken of in connection with pernicious fever. 
/ Masked Intermittent. — In this connection I would in- 
vite your attention for a few moments to a form of inter- 
mittent fever, which by some writers has been designated 
masked intermittent fever. For example, to-day a patient 
has a regular intermittent paroxysm, but to-morrow, instead 
of its recurrence, perhaps, he suffers from the most intense 
neuralgia. This neuralgia may have its seat in the inter- 
costal or in the sciatic nerve, or perhaps more frequently in 
the frontal portion of the ophthalmic branch of the tri- 
gemini nerve. Some one nerve becomes involved and no 
other seems to be affected. 

In some cases, an intense hemicrania takes the place of 
the paroxysm. 

As a rule, these neuralgias have distinct intermissions, 
and so come to be regarded as masked forms of intermittent 
fever, v 

Instead of a neuralgia, your patient may have an attack 
of asthma, or an attack of indigestion. During the past 
year I have seen several cases of intermittent dyspepsia. 
The patient, after having had one or two distinct intermittent 
fever paroxysms, or perhaps only a slight chill, fever, and 
sweat, has suffered severely from indigestion, colicky pain 
in the bowels, and symptoms resembling those of perito- 
nitis. Diarrhoea, dysentery, and sometimes hsematuria and 
apparent suppression of urine, may take the place of a dis- 
tinct intermittent fever paroxysm. 

Again, your patient may have a single well-defined chill, 
or even two chills followed by most intense hemicrania, 
and then have no more for a long time, but sooner or later 



TREATMENT. 131 

lie will have a well-defined intermittent paroxysm which 
will reveal the real nature of the disease. 

Sometimes this form of intermittent fever instead of being 
a quotidian, a tertian, or a quartan, may be one in which 
the paroxysms are developed every sixth or seventh day. I 
might refer you to other types of this fever, which we might 
call masked intermittent, but which in their development 
do not present the regular phenomena of a fully developed 
paroxysm. 






LECTURE XII 



SIMPLE REMITTENT FEVER. 

Morbid Anatomy. — Etiology. — Symptoms. — Differential 
Diagnosis. — Prognosis. 

This morning I shall commence the history of Simple 
Remittent Fever, the second in my list of malarial fevers. 

This is a continued fever ; witli diurnal exacerbations. 
It is known by different names, such as Southern, Western, 
African, Continued, Bilious, Acclimative, and Remittent 
Fever. 

The term, Remittent Fever, is more generally accepted, 
and the one which I shall adopt. 

Morbid Anatomy. — In many respects, the anatomical 
lesions of remittent fever resemble those of intermittent 
fever, yet there are certain points of difference with which 
it is important that you should become familiar. These 
differences are rather in degree than in kind. 

Unquestionably, both these types of fever are the result 
of malarial poisoning ; therefore, we may expect the same 
diminution of the red globules and the same changes in the 
fibrin of the blood in remittent that we have noticed in pro- 
longed intermittents. Yet there are other changes in the 
blood, which we usually find present in the former, that 
are of quite rare occurrence in the latter, namely, the pres- 
ence of free pigment-granules. These pigment-granules 
are met with in some of the pernicious forms of intermit- 
tent fever ; but, in all cases of well-developed remittent 
fever, they are present at some time during the progress of 



MORBID ANATOMY. 133 

the disease. This pigmentation is dne to the hsematoidin 
which has its origin in the haemoglobin which has been 
liberated from the blood-corpuscles within the blood-vessels, 
and then developed in the liquor sanguinis. This coloring 
matter may remain either within the blood-corpuscles, 
which, after a time, become transformed into pigment- 
granules, or remain free in the fluid portion of the blood, 
or infiltrate the adjacent cells and tissues. It may be 
transformed into granular or crystalline hsematoidin. 

The spleen is not so much enlarged in remittent as in 
intermittent fever, and the increase in size seems to be of 
a different nature. The enlargement is evidently the result 
of congestion, and the organ sometimes presents very 
nearly the same appearance as it presents in typhoid fever, 
except that there is more pigmentation present, which is 
rarely present in a typhoid spleen. 

There are also structural lesions found in the liver, in 
the stomach, and in the intestines, which are not present 
in intermittent fever. The liver is not very much increased 
in size, and, in color, is of a bronze hue. The principal 
change is in color, which is uniform throughout its entire 
substance. This varies in degree in different types of the 
disease, and in different cases of the same type. The 
peculiar color is due to pigmentation of the liver tissues, 
and varies according to the amount of pigment deposited. 
Pigmentation may occur in other tissues of the body, but 
not to the same extent as in the liver. On a microscopical 
examination of the liver tissue, pigment is found through- 
out its entire structure — not only in the hepatic cells, but 
in the nuclei of these cells and in the walls of the blood- 
vessels. 

This discoloration is of such uniform occurrence that it 
has been recognized in different countries and by different 
writers as the characteristic pathological lesion of remittent 
fever. Consequently you will find in your books that the 
" bronzed liver " is spoken of as the characteristic lesion of 
this fever. Occasionally you may have the same pathologi- 
cal lesion in intermittent and pernicious fever, but this is so 
seldom, and its presence is so constant in remittent fever, 



134 SIMPLE EEMITTENT FEVEK. 

that if you meet with ifc at an autopsy you may venture 
upon the diagnosis of remittent fever. 

Stomach. — You will find the mucous membrane of the 
stomach more or less congested, thickened, and softened. 
In this respect the disease is somewhat allied to typhoid 
fever. You will find similar changes also in the mucous 
membrane of the intestines ; it is more or less congested, 
and presents very much the appearance seen when a mod- 
erately severe catarrhal inflammation is present. The Peye- 
rian patches are usually enlarged, and quite frequently 
present the " shaven beard" appearance. In some cases 
there are ulcerations, not, however, as extensive or of the 
same nature as the ulcerative processes of typhoid fever. 
The mesenteric glands are not enlarged, and there is none 
of that granular infiltration in the glands so noticeable in 
typhoid fever. There is only a simple hyperemia, entirely 
due to a catarrhal inflammation. Thus you notice in tak- 
ing up the history of each of these fevers, that while each 
one is a distinct disease, we find many things that are com- 
mon to all of them. There is in all some pathological 
change which seems to link them together. 

The same changes may occur in the muscular tissues of 
the body, which are met with in typhus and in typhoid 
fever, and they are claimed by some to be the result of 
prolonged high temperature ; yet in remittent fever the 
temperature rises higher than in typhoid, while these mus- 
cular degenerations are of rare occurrence, and less exten- 
sive when present. The more we study these fevers the 
more disposed, it seems to me, will we be to attribute these 
granular degenerations to something besides high temper- 
ature. 

The most important characteristic change, and perhaps the 
only one, in all malarial fevers, is the change which takes 
place in the blood-globules. 

Etiology. — The great predisposing and exciting cause of 
this fever is malarial poisoning. There can be no question 
but that the same malarial poison which gives rise to inter- 
mittent fever can produce a remittent fever. In other 
words, we have remittent passing into intermittent fever, 



ETIOLOGY. 135 

and intermittent passing into remittent fever. While it is 
possible for this to occur, as a rule the two diseases do not 
prevail in the same locality at the same time. Endemics of 
one form may occur and be followed by endemics or spo- 
radic cases of the other form. In some localities remittent 
fever is almost the only form of malarial disease, intermit- 
tent fever only occasionally occurring. 

There is probably no form of endemic disease, the geo- 
graphical boundaries of which are more extensive than 
those of remittent and intermittent fever. With certain 
exceptions they may be said to encircle the earth by a 
broad belt, parallel with the equator, limited by 63° north 
latitude, and by 57° south latitude. The boundaries of this 
belt are quite irregular, now approaching the line of the 
tropics, now receding from it. 

The remittent fever which occurs within the northern or 
southern limits of this belt is much less severe than that 
which occurs in the tropical regions. From the localities 
in which this fever prevails it would seem that a higher 
average temperature is required for its development than is 
required for the development of intermittent fever. In cer- 
tain portions of this immense tract cases of remittent fever 
are never seen ; especially is this the case at a distance from 
the equator, while in the tropical regions the places of ex- 
emption are comparatively few. 

As I have already stated, a remittent fever during its 
convalescence may become an intermittent, and, conversely, 
an intermittent, either from new exposure to malarial in- 
fluences or to the influence of high temperature, may be- 
come a remittent. From this fact the conviction is forced 
upon us that under differing circumstances both these 
types of fever may be developed from a common malarial 
poison. Usually certain atmospheric changes will have 
taken place to change the type of the fever. They rarely 
prevail endemically at the same time. For instance, inter- 
mittent fever may prevail early in the season, but as the 
season advances, and the temperature ranges higher, the 
fever which prevails will assume the remittent type. 

Some claim that each of these two forms of fever has a 



136 SIMPLE EEMITTENT FEVER. 

distinct malarial poison, but I believe the difference to be, 
not in kind, but in degree. There are certain circumstances 
which predispose one person more than another to an attack 
of remittent fever. For instance, those who go from a non- 
malarial district into one where remittent fever is prevailing 
are more likely than those who live in the infected district 
to have this fever. 

Remittent fever is governed by the same laws in its de- 
velopment that govern the other forms of malarial fever. 

It prevails along the banks of rivers ; the miasm which 
produces it may be conveyed by the wind; it occurs in 
marshy regions where there is but little water. When the 
same localities in which intermittent prevails are exposed 
to a higher degree of temperature, remittent fever may 
be developed. These laws have already been sufficiently 
considered under the head of malarial poisons. 

Symptoms. — The ushering- in symptoms of remittent fever 
are usually more marked than those of any other form 
of continued fever. 

The most constant as well as the most urgent of the pre- 
monitory symptoms is oppression in the epigastrium. This 
may be present for forty-eight hours, or even a longer time, 
previous to its development. There is also a certain 
amount of lassitude, nausea, and loss of appetite, and 
with these feelings uneasiness and perhaps pain in the head 
and limbs. There is very much the same feeling of general 
discomfort that precedes the development of typhoid fever. 
But the disease does not come on gradually, as does typhoid 
fever, but abruptly, usually with a chill. There is no ques- 
tion as to when the patient began to be sick. The cold 
stage is neither so complete nor so long continued as it is in 
intermittent fever or pneumonia. 

It is of importance that you remember this peculiar fea- 
ture. During the chill the thermometer will indicate a 
temperature two or three degrees above the normal. With 
the chill there is a most intense headache, pain in the back 
and limbs. Following the chill, there is fever, during which 
the temperature rises very rapidly. The fever increases in 
severity, and, within twelve hours from the time of its 



SYMPTOMS. 137 

commencement the temperature will have reached 105° or 
106° F. As a rule, the chill is not of so long duration as 
the chill of intermittent fever, neither does it begin, like it, 
by creeping down the back and gradually extending over 
the body, but there is general coldness over the surface of 
the body at the very commencement of the chilly sensation. 
Again, there is not that tremulousness and shaking of the 
body, neither that chattering of the teeth, which is so fre- 
quently experienced in intermittent fever. In a few words, 
the chill of remittent is not so severe as that of intermittent 
fever. 

As soon as the temperature commences to rise, the pulse 
is increased in frequency, and perhaps reaches 100 or 120 
beats to the minute. The face becomes flushed, but not so 
intensely flushed as in the second stage of intermittent 
fever. The eyes are usually suffused, and the conjunctiva 
is somewhat congested. The patient is restless, tossing in 
bed, in the vain search of an easy posture. As the hot 
stage advances, nausea and vomiting are always present, 
and the sense of oppression in the epigastrium increases, 
which is not relieved by vomiting. 

In making a diagnosis, remember that this disease is 
ushered in by a chill, followed by a fever, which is accom- 
panied by nausea, vomiting, and great distress in the epi- 
gastrium. 

We have nausea and vomiting occurring in intermittent 
fever, but it is not so persistent and distressing in character 
as the nausea and vomiting of remittent. Again, there is 
not the same amount of pain in the epigastrium, for in the 
febrile stage of remittent fever the patient suffers from it to 
such an extent that quite commonly it is the only thing 
of which he complains. 

Before this, there has been a sense of oppression and 
perhaps pain in the epigastrium, but during this period 
the epigastric distress is very great, and is often accom- 
panied by the most extreme tenderness upon pressure. The 
material first vomited simply consists of the contents of the 
stomach, next follows the vomiting of a greenish matter, 
and finally, in severe cases, even of simple remittent fever, 



138 SIMPLE EEMITTENT FEVER. 

you may have a slight amount of black vomit. This 
resembles the black vomit of yellow fever. The quantity 
of fluid vomited is greater than the quantity taken into the 
stomach. 

Yo mi ting of stringy mucus tinged with green is always 
present in remittent fever. Sometimes the patient's stomach 
rejects everything taken into it, and the vomiting is accom- 
panied by terrible distress in the stomach, pain in the head, 
and general disturbance of the system. 

At the commencement of the fever, usually, the bowels 
are constipated. 

The symptoms thus described go on increasing in severity 
for ten or twelve hours, then you will notice a slight amount 
of perspiration upon the forehead. In a short time, it ex- 
tends over the entire body, not profuse, but a slight moist- 
ure upon the surface. With the perspiration will be a fall 
of one or two degrees in temperature, and a fall of ten or 
twenty beats in the minute rate of the pulse. The thirst 
will diminish, the vomiting grow less, there may now be 
ability to retain fluids taken into the stomach, and the 
patient falls into a quiet, refreshing sleep, and is relieved 
from all the severer symptoms of the paroxysm. If, how- 
ever, you will place the thermometer in the axilla, you will 
rind that evidences of fever still exist, and although there 
has been a marked decline in temperature, it does not reach 
the normal standard. At no time is there a complete in- 
terruption; the fever is continuous. This is termed the 
period of remission. At the same time on the following 
day all the active febrile symptoms return, increased in 
severity, the range of temperature is higher, the gastric 
disturbance is more marked and severe, the countenance 
assumes an anxious expression, and all the symptoms are 
more severe. 

This return of the severe febrile symptoms constitutes 
what is called the exacerbation, and the period between the 
time when the fever abates and the development of the ex- 
acerbation is called the period of remission. Remissions and 
exacerbations are the characteristic symptoms of a remittent 
fever when it is fully developed, at which time a morning 



SYMPTOMS. 139 

remission is the rule, though the time of the first paroxysm 
varies. If the exacerbation begins at noon, it will usually 
decline about midnight, and the remission will last until 
about noon the next day. In very severe cases there may 
be a double exacerbation, one at noon, the other at mid- 
night, the remissions being in the evening and morning. 
The second exacerbation is similar to the primary in its 
attendant phenomena, except that it is more severe and of 
longer duration, ends in a less profuse perspiration, and the 
remission is not so well marked as the first. 

On the third day, at about the same hour, or a little 
earlier, we again have the exacerbation, which has a still 
longer duration, is of greater severity, and is followed 
by a more incomplete remission. If the disease goes on 
from day to day, the remission becomes less and less dis- 
tinct, and the case becomes dangerous just in proportion as 
it loses its paroxysmal character. By the end of the first 
week the remission can no longer be detected, and the fever 
becomes a continued fever, without any marked daily vari- 
ation in temperature or pulse. As the remissions become 
less and less distinct, with each returning exacerbation the 
tongue becomes more and more parched, sordes collect 
upon the teeth, the countenance becomes dull and heavy, 
distress and pain in the epigastrium continues, and is ac- 
companied by tenderness, although the senses of the patient 
are so dulled that he may scarcely complain of it ; the 
vomiting is not so constant, and is of a less distressing 
character ; constipation, which was probably present at the 
commencement of the fever, has now given way to diar- 
rhoea! discharges, which are usually of a brownish color. 
With the diarrhoea there is some fulness of the abdomen, 
and some local tympanitis. The pulse is increased in fre- 
quency, and has perhaps reached 120 or 130, is small, 
thready, and feeble, while at the onset of the disease it was 
full and compressible. The patient slips down in the bed, 
picks at the bed-clothes ; there is subsultus and difficulty 
in deglutition, and the tongue is protruded with difficulty, 
as in the severer forms of typhoid fever. In other words, 
the patient has passed into a condition closely resembling 



140 SIMPLE REMITTENT FEVER. 

that of one who has entered the third week of a typhoid 
fever, with this exception, there is no eruption. 

The diarrhoea, abdominal disturbance and tympanitis, 
and often the tenderness over the ileo-csecal region, the 
typhoid tongue, and the low muttering delirium, closely 
allies this stage of simple remittent fever to typhoid fever ; 
but the absence of the rose-colored spots and the typical 
range of temperature of typhoid fever are sufficient to dis- 
tinguish it from that fever. 

After these typhoid symptoms have continued a week or 
ten days, if the case is to terminate in recovery, remissions 
recur and become more and more distinct, until finally 
there is no exacerbation, and the patient passes into a state 
of convalescence. If, however, a fatal termination is to 
take place, the remissions will not recur, but the typhoid 
symptoms will become more marked, and the patient will 
finally die from exhaustion or from complications. Of all 
the symptoms which attend simple remittent fever, nausea 
and vomiting are the most constant and the most distress- 
ing. I have seen patients, after the temperature had fallen 
to its normal standard, suffer for weeks from gastric dis- 
turbance, attended by more or less jaundice. 

If, in the progress of a remittent fever, the exacerbation 
occurs a little earlier each day, then treatment is not con- 
trolling it, but the disease is gaining ground ; the fever is 
then said to be anticipating, and you may be almost cer- 
tain that the disease is passing from a distinct remittent to 
a continued remittent. 

If, on the other hand, the exacerbation occurs a little 
later each day, the fever is said to be postponing, and you 
may be sure that you are controlling it, and that, as the 
remissions become longer, the exacerbations will become 
shorter and less severe, until the patient reaches complete 
convalescence. The thermometer will indicate to what ex- 
tent the disease is being controlled. 

This is the history of what may be regarded as simple re- 
mittent fever. It begins with a chill, is followed by distinct 
exacerbations and remissions, and, if not controlled by 
treatment, becomes a continued fever ; then, after a week, 



SYMPTOMS. 141 

perhaps a longer time, the remissions recur again until con- 
valescence is established, or the typhoid symptoms become 
more marked, the remissions do not recur, and death ensues. 

If a simple remittent fever is protracted, the typhoid 
symptoms which are developed do not stamp it with a 
typhoid character ; they are such symptoms as are liable 
to occur in any acute, infectious disease. 

Bilious Remittent Fever. — In a certain proportion 
of cases, in all endemics of remittent fever, vomiting of 
" bilious " material, and jaundice are prominent symptoms, 
the skin often becoming so yellow that the patients pre- 
sent an appearance similar to those suffering from yellow 
fever ; with this yellow discoloration of the skin there is 
an unusual tenderness on pressure over the hepatic region. 
Under such circumstances this fever has been named u bil- 
ious remittent." 

By some of the older writers it has been described as an 
idiopathic fever, distinct from remittent or any other form 
of malarial fever. Medical literature, however, contains no 
facts in support of such a view. The pathology and symp- 
tomatology of the fever described by writers under the head 
of bilious remittent fever differ in no respect from those of 
simple remittent, except that the fever is accompanied by 
symptoms of more than usual hepatic and gastric disturb- 
ance. My own experience leads me to regard it as a form 
of simple remittent, accompanied by a more than usually 
severe gastro-hepatic catarrh, and that it is not entitled to 
a separate place in the nosology of fevers. 

Ineajsttile Remittent Fever. — In this connection it is 
perhaps well that I should refer for a moment to a con- 
dition which has received the name of infantile remittent 
fever. 

It is a matter of every-day experience that children are 
subject to certain gastric and intestinal derangements, 
which are attended by more or less fever, which is very apt 
to assume a remittent type. Such fevers cannot, however, 
be regarded as specific diseases, for they are developed 
independent of any specific fever poison, and are only 
symptomatic of some local irritation. There is a form of 



142 SIMPLE REMITTENT FEVER. 

mild typhoid fever which is often met with in children, 
especially in the autumn, which has also incorrectly received 
the name of infantile remittent fever. In this class of cases 
the nsnal symptoms of typhoid fever are so modified by 
age that the fever assnmes a remittent type. The presence 
of rose-colored spots, and the characteristic typhoid lesion 
of the intestines, will determine the true nature of these 
fevers. 

In malarial districts you will meet with a simple malarial 
remittent in children, which does not differ from the simple 
remittent of adults, and does not, therefore, require a sepa- 
rate description. Remittent fever in children is more liable 
to be followed by malarial cachexia than in the adult. 

Differential DIAGNOSIS. — I have already given you 
the rules by which you are to distinguish a simple remit- 
tent from a simple intermittent fever, and it is not necessary 
that I should repeat them. 

The differential diagnosis between remittent and typhoid 
fever is often attended with difficulty, if the patient is not 
seen until the second week of the disease, but if he is seen 
at the very onset of the fever, it is hardly possible to mis- 
take these two forms of fever the one for the other. The 
sudden advent of a remittent is in marked contrast to the 
slow development of a typhoid fever. Besides, they widely 
differ in the range of temperature during the first week of 
their development. In remittent there is a distinct remis- 
sion, and you need not doubt as to the type of fever after 
the first, certainly not after the second, remission has oc- 
curred. 

Again, you have the gastric symptoms, which are much 
more severe in remittent than in typhoid. By these symp- 
toms alone you will be able, in many instances, to make a 
differential diagnosis. If, however, the fever has been pro- 
tracted to the third week, and the remissions are slight or 
altogether absent, although many of the symptoms of 
typhoid fever are present, the absence of the rose-colored 
spots is sufficient, taken in connection with previous history 
of the patient, to establish the diagnosis. Should you 
be still in doubt, place a drop of the patient's blood under 



DIFFERENTIAL DIAGNOSIS. 143 

the microscope, and in nearly eyery instance, if the case be 
one of remittent fever, pigment granules will be seen, which 
at once settles the question, as pigment granules are not 
found in the blood of typhoid fever patients. 

Finally, remittent fever is developed only in malarial dis- 
tricts, and there can be no difficulty in making a differen- 
tial diagnosis, if the patient resides in a non-malarial 
district, and is not known to have been exposed to malarial 
influences. 

If hemorrhages occur during the course of a remittent 
fever, the blood proceeds from the mouth, nose, urinary 
organs, and bowels ; while in the advanced stages of 
typhoid fever it rarely occurs, except from sloughing of 
the intestinal glands. 

Simple remittent fever may be distinguished from yellow 
fever by its high range of temperature, by its daily exacer- 
bation and remission, by the presence of pigment in the 
blood, and in most cases by the absence of albumen in the 
urine, which is present in yellow fever. 

In remittent fever, hemorrhage from the mucous surfaces, 
especially from the mucous membrane of the stomach, is 
of rare occurrence, while in yellow fever it is frequently 
present. 

Death often occurs on the third day in yellow fever, but 
in the severest cases of remittent fever not before the sev- 
enth day. 

Remittent fever may be confounded with pyaemia and 
septicaemia, but their differential diagnosis has already been 
sufficiently considered under the head of intermittent fever. 
The differential diagnosis between remittent and typho- 
malarial fever will be considered when I come to the latter 
disease. 

Prognosis. — The prognosis in simple remittent fever 
is good ; death should rarely occur. Even cases of the 
severe types of this fever should terminate in recovery, if 
skilfully managed, especially if they are seen in the early 
stages of the disease. 

You must remember that the type of this fever varies 
very much according to locality. The remittent fever 



144 SIMPLE REMITTENT FEVER. 

which we see in this city is of a mild type. In that form 
which prevails in many parts of the West and South a 
fatal termination is of frequent occurrence. 

There is a type which soon loses its remission, and be- 
comes a pernicious malarial fever, the prognosis of which is 
unfavorable. 

The prognosis will also be modified by the condition of 
the patient at the time of the attack, and by the character 
of the epidemic which is prevailing. 

I have already indicated the symptoms by which you are 
to determine whether recovery is to take place, or the case 
is to terminate fatally. The fact that the exacerbation is 
delayed or rendered less severe, is a favorable indication, 
unless the patient becomes more and more overwhelmed by 
the malarial poisoning, which condition is shown by a high 
range of temperature and a tendency to coma, or by the 
patient's passing into a typhoid state. The early sub- 
sidence of gastric symptoms, headache and a decrease in 
the frequency of the pulse, are favorable signs. Distinct 
remissions, accompanied by moderately free perspiration, 
indicate an approaching favorable change. On the other 
hand, if the fever is more continuous than paroxysmal, 
with a pulse becoming daily more feeble and more fre- 
quent, if there is a tendency to collapse at the close of the 
exacerbations, with signs of extreme exhaustion, danger is 
indicated. 

The average duration of this fever is two weeks. 

As this fever varies so greatly in severity at different 
times and in different localities, it is impossible to deter- 
mine its average rate of mortality. 



LECTURE XIII 



PERNICIOUS FEVER. 

Treatment of Simple Remittent Fever. — Morbid Anatomy. 
— Etiology. — Symptoms. 

We shall have completed the history of simple remittent 
fever when we have considered its treatment. 

When speaking of the treatment of typhoid fever, I 
stated to you that the fact was constantly to be borne in 
mind that there was no agent by means of which we could 
shorten its duration or arrest its development. The con- 
trary is true in this disease, for we have means at our com- 
mand by which, in the majority of cases, it can be con- 
trolled, and by which, in all instances, its duration may 
be very much shortened. It is hardly necessary for me to 
speak of such remedial agents as blood-letting, emetics, 
cathartics, and diaphoretics, which have all been employed 
in the treatment of this fever, for they have all been sup- 
planted by a single remedy. Perhaps there is no more 
difficult lesson for a young practitioner to learn, when 
brought to his first case of remittent fever, just as the 
patient is passing into his first exacerbation, certainly if he 
has reached his second, than to restrain himself from resort- 
ing to a vigorous antiphlogistic plan of treatment. As he 
feels the burning heat of the skin and the full, bounding 
pulse, and sees the flushed face and congested eye, and 
listens to the complaint of intense pain in the head and 
limbs, of unquenchable thirst, and burning pain in the 
epigastrium, he is almost impelled to resort to some, or all, 

of the more vigorous so-called antiphlogistic remedies ; but 
10 



146 PERNICIOUS FEVER. 

in this fever it is true, as in the other forms of fever which 
have been engaging our attention, that these violent symp- 
toms are due to a blood-poison which is exerting its specific 
effect upon the nerve centres. It is this, not an inflamma- 
tory process, that we have to contend with. Experience 
has proved that this poison cannot be removed from the 
system by any of the so-called eliminative methods of 
treatment. If you deplete this class of patients to any 
extent, you hasten the development of those typhoid 
symptoms which are especially to be avoided. Persons 
living in malarial districts are never up to the normal 
standard of vigor, and, consequently, are in a condition to 
be affected unfavorably by any plan of treatment or by 
any remedial agents which shall enfeeble the vital powers. 

The first thing to be done in the successful management 
of this fever is to place your patient under the best possible 
hygienic surroundings. The same care should be exercised 
in the arrangement of the sick-room as has already been 
proposed in the management of typhoid fever. Those who 
have seen most of remittent fever in its severer forms 
recommend that the treatment of each case be commenced 
by administering a mercurial purge. They claim that there 
is always more or less engorgement of the liver, spleen, and 
mucous membrane of the stomach and intestines, and that, 
so long as these organs remain in this condition, no plan of 
treatment will be successful. 

However great may be the differences of opinion in 
regard to this, all agree that the sulphate of quinine should 
be used in the treatment of this fever. Practitioners differ, 
however, as to the mode of its administration, but all are 
united in its use. Some maintain that it has greater power 
over the disease when administered in small doses, re- 
peated at short intervals ; others maintain that it should be 
given in one or two large doses during the remission, an 
hour or two before the commencement of the expected ex- 
acerbations. Again, others claim that the quinine has its 
greatest power over the fever when administered during 
the activity of the febrile excitement. A few years ago this 
subject was carefully studied by those engaged in the Eng- 



TBEATMENT. 147 

lish Medical Service in India. Under the direction of the 
Surgeon-General in that department quinine was adminis- 
tered at different periods in the course of the fever. For 
example, one surgeon gave quinine at the commencement 
of the exacerbation, another gave it immediately after the 
exacerbation had passed its height and as the sweating 
stage was coming on, another gave it immediately preced- 
ing the exacerbation, and others gave it during the remis- 
sion. This plan was adopted in order to determine with 
positiveness when the smallest amount of quinine would 
have the greatest controlling effect over the fever. From 
the various branches of the department reports were made 
to the Surgeon- General, and from these reports the conclu- 
sion was arrived at, that quinine, administered during the 
time of the exacerbation, had not only a greater influence in 
diminishing the severity of the disease, but it also more 
completely controlled the fever, and more markedly short- 
ened its duration than when it was administered during the 
remission. From the conclusion arrived at from their re- 
ports, and from my own experience, I should not hesitate 
to administer quinine at any time during the period of ex- 
acerbation or remission. My rule is to give ten or twenty 
grains at a dose, according to the severity of the fever, and 
repeat it every two hours until cinchonism is produced. 
When cinchonism is reached, although the fever may not 
be controlled, it is well to stop its administration until 
twenty-four hours have elapsed ; by doing this you will be 
better able to determine the antiperiodic power of the 
drug. If you find that the exacerbations do not disappear, 
but are delayed and are less severe, you may be sure that 
you are controlling the fever. If, notwithstanding this 
free use of quinine, the exacerbations are more severe and 
longer in duration, and the remissions less frequent, and 
typhoid symptoms are manifesting themselves, stimulants 
may be demanded. Even large doses of stimulants may be 
required to sustain the patient while he is passing through 
this period of the disease. 

Remittent fever is not, like typhoid fever, a disease of 
days or weeks. In its severer forms, no time should be 



148 PERNICIOUS EEVER. 

lost while waiting for the action of cathartics or other 
remedial agents which are supposed to be of importance, 
but you should at once commence the administration of 
quinine. When the disease has reached its second or third 
week, and there is no evidence that the patient is passing on 
towards recovery, you must commence a second time the 
administration of large doses of quinine ; in this way you 
may arrest the progress of the fever. If, after a second cin- 
chonism is produced, the fever is not arrested, you must 
again omit for a few days the administration of quinine ; 
then repeat the large doses a third time. It is much better 
to proceed in this way with the remedy than to keep your 
patient in a continued state of cinchonism. It is not neces- 
sary to enumerate the long list of drugs which at different 
times have been proposed as specifics in this fever, all of 
which, by common consent, are now regarded as far less re- 
liable than quinine. The important thing is to know how 
and when to administer quinine. 

There are certain palliative measures which it is some- 
times important to employ. If the exacerbations are very 
intense, the headache very severe, and the restlessness or 
other febrile symptoms are not relieved by full doses of 
quinine, you may resort to the use of cold for its antipy- 
retic effect, the same as in typhoid fever. 

Frequently, in mild cases, sponging the surface with 
tepid water is not only grateful to the patient, but it has a 
controlling influence over the fever. If vomiting is constant, 
severe, and exhausting, hypodermics of morphine will be 
found of service. 

As in typhoid, the treatment of this fever is expectant, 
save in the use of quinine. 



PERNICIOUS MALARIAL FEVER. 

I now pass to the next in my list of maiarial fevers, which 
I shall describe under the term of pernicious fever. This 
form of fever has received other names, at different times 
and in different localities. It has been called congestive 



MORBID ANATOMY. 149 

fever, ardent fever, tropical typlioid fever, and pernicious 
fever. 

I have adopted the latter name, for it seems to me to be 
not only the most appropriate, bnt the one which at the 
present time is most generally adopted. It is true that in 
the majority of cases there is more or less congestion of the 
internal organs, and sometimes the patient is overwhelmed 
by these congestions, but in a large number of cases no such 
congestions exist, and under such circumstances the desig- 
nation pernicious is mostly to be preferred. 

It is the most severe and dangerous form of malarial 
fever. It may be intermittent or remittent in character, 
and may assume any of the types of periodical fever, but 
the quotidian and tertian types are the most common. 
Sometimes its pernicious character is clearly marked at the 
onset of the fever, during the first paroxysm ; at other 
times it comes on insidiously, and its pernicious character 
is not suspected until after the occurrence of two or thre^ 
paroxysms. 

There are several well-marked and distinct varieties of 
pernicious fever — the most common and most important of 
which are the comatose, the delirious, the algid, and the 
g astro- enteric. Almost every locality where pernicious 
fever prevails gives to the fever some distinctive pecu- 
liarity. 

Pernicious fever not infrequently appears as an epidemic, 
although sporadic cases are met with in those regions where 
simple intermittent and remittent fevers prevail. I have 
seen six well-marked cases of pernicious fever in this city 
during the past year. 

Morbid Ax atomy. — The anatomical lesions of pernicious 
fever are similar in kind to those found in simple intermit- 
tent and remittent fevers, but they differ very much in 
degree. For instance, you will find similar blood-changes, 
the most striking of which is the presence of free pigment 
in the blood. But the pigmentation is more abundant, and 
the pigment material may be in the form of granules, or in 
the form of plates, or it may even have a cellular outline. 
The abundance of the pigment, and the extent of the pig- 



150 PERNICIOUS FEVER. 

mentation will vary according to the severity of the fever 
Bnt in all cases there is some free pigment in the blood. 
This pigment is not often present in the blood in simple 
intermittent, unless the fever has been prolonged, and in 
simple remittent it is never as abundant as in pernicious 
fever. 

The other changes in the different organs and tissues of 
the body are very similar in character to those to which I 
have already referred in connection with the morbid anat- 
omy of intermittent and remittent fever. 

As the varieties in type of this fever are as numerous as 
the localities in which they occur, and as the type in any 
locality may change with every succeeding year — that is, 
the type of one year may be very unlike that of the preced- 
ing or following year — you see that it is very difficult even 
to classify its different forms. 

The slight variations which are met with in the patho- 
logical lesions of the different varieties, are still more diffi- 
cult of description and classification. For instance, there 
is one variety which is characterized by a tendency to 
coma, called the comatose variety ; another is characterized 
by a tendency to a peculiar form of delirium, termed the 
delirious variety; still another which is characterized by 
a marble-like coldness of the surface, called the algid 
variety ; again, we have one which is characterized by 
vomiting and purging, or choleraic symptoms, termed the 
gastro-enteric variety ; then one in which there is acute 
jaundice, termed the icteric variety; then one in which 
there are profuse -hemorrhages, termed the hemorrhagic 
variety, and still another in which there is profuse diapho- 
resis, termed the colliquative variety. 

These are the more common varieties of pernicious fever. 
There are still others of such rare occurrence that it is hardly 
necessary that I should mention them, as they are slight 
variations due to local causes. None of these are distinct 
fevers, but different types of the same fever. 

As in scarlatina, measles, and small-pox, we have differ- 
ent-names assigned to different types of the same disease, 
so all these forms of pernicious fever are simply different 



MORBID ANATOMY. 151 

manifestations of one and the same fever, due to one and 
the same cause, namely, malarial poisoning. 

You will find the post-mortem appearances in pernicious 
fever varying with the intensity of the malarial infection, 
and the peculiar atmospheric conditions under which the 
fever is developed. 

In some instances there will be evidences of intense 
engorgement of the blood-vessels of the brain, and the entire 
brain substance will be more or less thoroughly stained 
with pigment material. In others, minute blood-extravasa- 
tions will be found scattered here and there throughout the 
substance of organs. Small blood-extravasations into the 
spinal cord, accompanied by more or less pigmentation, is 
very apt during life to be attended by tetanic spasms. In 
persons dying of pernicious fever after the third attack, I 
have found all the organs of the body pigmented. 

Sometimes you will find intense engorgement of the liver, 
that is, the most marked post-mortem changes will be found 
in that organ, and the amount of pigmentation present will 
correspond with the intensity of the congestion. With 
intense engorgement of the organ there are usually blood- 
extravasations. 

Occasionally, infarctions occupy the spleen, around which 
there will be a mass of pulpy material. The spleen is more 
frequently found softened in this form of malarial fever 
than in those forms already described. Although enlarged, 
it is usually softened and of a darker color than normal. 
It is sometimes so soft that it closely resembles the spleen 
of typhoid fever, and is merely a pulpy bloody mass, though 
in size it is larger than in typhoid fever. If not softened 
it may have infarctions scattered through its substance. 
Marked pigmentation of the tissues of the body, correspond- 
ing in amount with the peculiar symptoms present during 
life, a tendency to enlargement and softening of the spleen, 
enlargement of the liver with deeper pigmentation than is 
seen in any other organ of the body, are among the more 
common pathological lesions of this form of fever. It is 
unnecessary to describe in detail that enlargement of the 
capillary vessels which occurs as a necessary result of this 



152 PERNICIOUS FEVER. 

intense engorgement. Sometimes the kidneys and the lungs 
are the seat of this intense hyperemia, as the result of which 
the functions of these organs are more or less extensively 
interfered with. 

Etiology. — The exciting and predisposing causes of per- 
nicious fever differ from those of the simpler forms of mala- 
rial fever only in degree, not in kind, but a higher range of 
temperature is requisite for the development of pernicious 
fever. It prevails only in those localities where the average 
range of temperature, for a time, reaches 65° F. 

Symptoms. — Pernicious fever may commence abruptly, 
but generally the premonitory symptoms which mark its 
development do not differ from those which mark the de- 
velopment of simple intermittent and remittent fever. In 
most varieties the attack commences with a chill, which is 
unusually severe and prolonged. In many cases you will 
have a distinct malarial paroxysm of either the intermit- 
tent or remittent type, and the pernicious character of the 
fever is engrafted upon it. In other words, you may 
have the attack commencing with a distinct intermittent 
fever paroxysm of the quotidian type, but rarely more 
than two of these intermittent paroxysms will occur 
before it assumes the pernicious type, if it is to become a 
pernicious fever ; or you may have a remittent fever with a 
distinct exacerbation and remission, which may go on for 
four or Hvg days before its pernicious character will be 
developed. 

The milder form either gradually passes from a simple 
intermittent into a pernicious fever by a progressive increase 
in the severity of the symptoms, or a single paroxysm of 
not unusual severity is suddenly followed by a pernicious 
one ; this latter seldom proves fatal, unless it has been 
repeated for the second or third time. Again, you may 
have a distinct chill followed by a condition that you will 
at once recognize as one of the varieties of pernicious fever. 
The ushering-in symptoms will always vary with the type 
of disease which is about to be developed. 

I shall not attempt to describe the phenomena that attend 
all these different varieties, but will only speak of those 



SYMPTOMS. 153 

most commonly met with, and detail their prominent and 
leading symptoms. 

Comatose Variety. — We will suppose that a patient 
has a distinct paroxysm of one of the simpler forms of 
malarial fever, either intermittent or remittent, with no 
special phenomena attending it, except that he has had a 
more severe headache than ordinarily occurs in a simple 
form of malarial fever ; with this perhaps there has been 
vertigo, a stammering and indistinctness in the speech, an 
inability to talk with freedom, and a more than usual trem- 
ulousness during the hot stage. From this condition he 
passes as usual into the hot stage of an intermittent, or 
rapidly into an exacerbation of remittent, then into a state 
of stupor and unconsciousness, and finally lies upon his 
back, with a flushed face, congested conjunctiva, dilated 
pupils ; slow, deep, stertorous respiration, and perhaps a 
very slow pulse, or, if slow at first, it may soon become 
frequent. The axillary temperature ranges from 105° F. 
to 107° F. The patient is now nearly unconscious ; he is 
apparently paralyzed ; the urine is retained in the bladder, 
and the bowels move involuntarily. If the pulse is slow, it 
is full and hard. ' The respiration becomes more and more 
stertorous, unconsciousness becomes more and more com- 
plete, until he finally dies in a state of complete coma. 
Usually, however, a moisture makes its appearance within 
twelve hours from the commencement of the first parox- 
ysm, and the patient awakes to consciousness in the midst 
of a profuse perspiration. The headache and giddiness 
have now nearly passed off, and if the fever which preceded 
it was remittent, there may be a well-marked remission ; if it 
was an intermittent, there may be a distinct intermission. 
With the next remittent exacerbation or the hot stage of 
intermittent, the pain in the head, giddiness, unconscious- 
ness, and all the symptoms already described will return 
more intense in character than before, with the coma and 
stupor, and perhaps with the second attack the patient 
passes into a fatal coma. These are the leading phenomena 
which attend the most common form of pernicious fever. 

In this variety patients sometimes pass into a condition 



154 PEENIOIOUS FEVEE. 

of apparent death, which may last for hours. Some are 
perfectly conscious, seeing and hearing everything which, 
occurs around them, while they are unable to move or utter 
a sound ; others pass into a state of unconsciousness, but 
the respiratory movements and the heart's action are not 
perceptible. Even though the strongest counter-irritants 
be applied to the surface, there is no sign of life, until, at 
the beginning of the sweating stage, the patient comes to 
himself. 

If a patient survives the first paroxysm of this form of 
pernicious fever, quite probably he will die during the 
second. With each successive paroxysm the prognosis 
becomes more and more unfavorable ; patients sometimes 
lie in a comatose condition for days, and finally die appar- 
ently from cerebral compression. 

/ Delirious Variety. — In this variety your patient, after 
passing into the hot stage of an intermittent or into the ex- 
acerbation of a remittent, becomes delirious. Mild delirium 
is not uncommon during the progress of an intermittent 
or a remittent fever, but the delirium now referred to is of a 
more active character. If then delirium is developed during 
the exacerbation of a remittent or during the hot stage of an 
intermittent, which has been preceded by severe headache, 
dizziness, ringing in the ears, and great restlessness, you 
may be quite certain that you have to deal with a case of 
pernicious remittent or of pernicious intermittent fever, 
especially if pernicious fever is prevailing in the locality. In 
this variety of pernicious fever there will also be more or 
less headache during the interval, and perhaps other pecu- 
liar cerebral phenomena. v The delirium which appears is 
always violent in character ; perhaps the patient will require 
restraint ; he may be disposed to jump out of a window, or 
in some way to do injury to himself or those around him. ^ 

During the paroxysm of delirium the patient's face be 
comes flushed, his eyes brilliant, the conjunctiva injected, 
the pupils dilated, and he is constantly crying, singing, and 
trying to escape. In those who are extremely anaemic the 
countenance assumes a pale, sunken aspect. The pulse is 
full and hard, and the carotids beat violently, the tempera- 



SYMPTOMS. 155 

toe often reaches 107° F. or 108° F. The patient may re- 
main in this delirious state for hours. Somewhat suddenly 
he passes from it into a condition of collapse, or he gradu- 
ally sinks into a coma from which he never awakens. Dur- 
ing the whole period the axillary temperature rarely falls 
below 105° F. In favorable cases the delirium gradually 
becomes milder, a profuse perspiration comes on, and the 
patient falls into a prolonged sleep, from which he awakes 
conscious, though weak and exhausted, with headache and 
vertigo, but without the slightest recollection of what has 
passed. These attacks of delirium may be repeated three 
or four times before a fatal termination is reached, but so 
much danger attends them, that a second attack should 
never be allowed to occur if it can be prevented. 

In this variety of pernicious fever, other nervous pheno- 
mena may accompany or take the place of the delirium, such 
as epileptiform convulsions, tetanic spasms, etc. The teta- 
nic spasms sometimes assume the phenomena of hydropho- 
bia. 

That form of tetanus which occurs in various malarial 
districts, which is sometimes called sporadic tetanus, I be- 
lieve will be found to be of this type, and simply a form of 
pernicious fever. 

Gastro -Enteric Variety. — In this variety the patient, 
after he has passed into the hot stage of an intermittent or 
the exacerbation of a remittent, is seized with almost inces- 
sant vomiting and purging. The vomiting and purging is 
of a peculiar character, altogether unlike that which is 
sometimes present in the simpler forms of malarial fever. 
There is blood-stained material, both in the matter vomited 
and in that discharged from the bowels. In some instances, 
the discharges may be so reddened as to look like beef- 
brine or the washings of raw beef ; sometimes the propor- 
tion of blood is so great as to cause the discharges to have 
the appearance of clear blood. In some endemics the dis- 
charges assume the appearance of rice-water, having no 
odor, and similar in appearance to those in Asiatic chol- 
era. The patient has no abdominal pain or tenderness, but 
has a sense of- weight and burning in the stomach, accom- 



156 PERNICIOUS FEVER. 

parried with cramp in the calves of trie legs, coldness and 
blueness of the surface, with a small, almost imperceptible 
pulse, sunken eyes, and the facies of cholera. So closely 
do these patients resemble in appearance those with Asiatic 
cholera, that this disease has frequently been mistaken for 
cholera. During the attack the thirst is most intense. The 
respiration is peculiar ; it consists of a double inspiration, 
followed by a double sighing expiration. The restlessness 
is very great, the patient is constantly tossing from one 
side to the other ; sometimes he suddenly, an hour or two 
before death, springs up and walks across the room. The 
usual length of the fatal paroxysm is from three to six 
hours. Patients die in a state of collapse ; after the vomit- 
ing and diarrhoea have assumed the characteristic appear- 
ances already described very few patients recover. As death 
approaches, the pulse becomes more and more frequent, 
feeble, irregular, and fluttering in character. The respira- 
tion is more and more prolonged and sighing, the skin cold 
and shrivelled, and covered with a cold, clammy perspiration. 
It frequently happens when all these symptoms are present 
that the patient cannot be convinced that he is seriously ill, 
and wishes to get out of bed and go out of doors. 

It is important to remember that these three varieties of 
pernicious fever, which I have just briefly described, are 
not always distinct, but the symptoms of one may be 
mingled with those of another ; such mixed cases are very 
difficult to classify. 



LECTURE XIV. 



PERNICIOUS FEVER. 

Symptoms {continued). — Differential Diagnosis. — Progno- 
sis. — Treatment. 

At my last lecture I spoke of the comatose, delirious, and 
the g astro-enteric variety of pernicious fever. I now in- 
vite your attention to the consideration of another variety, 
which bears a striking resemblance to the one we last con- 
sidered. It is termed the algid variety of pernicious fever. 

Algid Variety. — This variety is characterized by coldness 
of the surface of the body, while the rectal temperature 
may range from 104° F. to 107° F. The attack begins with 
a chill of not unusual severity or duration, but soon after 
the patient enters the hot stage of the paroxysm ; or, during 
the exacerbation of a remittent, the surface of the body be- 
gins to grow cold, while at the same time he complains of 
a sensation of burning and intense thirst. A cold perspira- 
tion soon covers the surface. The pulse becomes slower and 
slower, falters, and disappears at the wrist. Alternately 
the extremities and face become cold ; only the abdomen 
retains its normal temperature. The surface has a cold, 
marble-like feel, but the temperature in the axilla never or 
rarely falls below the normal standard. In the comatose 
and delirious varieties the temperature rises higher than 
normal, and may reach 106° F. or 107° F., but in this vari- 
ety it sometimes falls two or three degrees lower than nor- 
mal. The tongue becomes white, moist, and cold ; the 
breath is cold, and the voice feeble and sunken. The action 



158 PERNICIOUS FEVER. 

of the heart is feeble, often perceptible only on ausculta- 
tion. The mouth is clean, and the patient seems to himself 
to be in a comfortable condition, except that he feels ex- 
hausted. The expression of countenance is that of death. 
In its progress this variety of pernicious fever is very insid- 
ious. If you are not familiar with it you will quite proba- 
bly mistake the calm which follows the febrile excitement 
for relief, perhaps attribute it to some plan of treatment 
which you have pursued, or to some remedial agent which 
you have employed. If a patient in one of these paroxysms 
is to pass on to recovery, the pulse gradually returns in the 
wrist, and the surface regains its normal feel and tempera- 
ture. As the warmth returns to the surface the patient 
passes on to convalescence in the same manner as patients 
recover from a comatose or delirious paroxysm. 

An algid pernicious paroxysm is rarely preceded by a 
distinct intermission, and it rarely has any appreciable re- 
mission. Once established, it marches steadily on to a 
fatal issue, unless arrested by treatment. 

There is another variety which you will occasionally meet 
with, in which a profuse perspiration, called a " colliquative 
sweat" comes on at the end of the fever stage and continues 
through the succeeding intermission, accompanied by great 
prostration, feeble heart action, and labored respiration. 
Upon the second or third return of this sweat the patient 
sinks and dies apparently from exhaustion. 

Again, severe hemorrhage from the stomach, bowels, or 
kidneys may occur during the sweating stage of a perni- 
cious paroxysm and endanger the life of the patient from 
sudden syncope. 

A mild form of haematuria sometimes occurs independent 
of a pernicious paroxysm in chronic malarial poisoning. 

There is still another variety, concerning which I will say 
a few words. It is always endemic, confined to certain 
localities, occurring in those localities when any form of 
pernicious fever prevails. It is called the icteric variety. 

Icteric Variety. — This variety begins with a violent, 
long- continued chill, during which jaundice shows itself. 
The jaundice gradually deepens, and extends over the whole 



DIFFERENTIAL DIAGNOSIS. 159 

body. Intense nausea accompanies its development, with 
a copious vomiting of bile, and a bilious diarrhoea. The 
patient suffers with a most intense headache, pain in the 
region of the spleen and over the kidneys, and a feeling of 
numbness in the limbs. The pulse is small, frequent, and 
hard. The urine is deep-colored. As the hot stage comes 
on the pulse becomes more frequent and fuller, the respira- 
tion is labored, the skin very hot, the temperature reaching 
106° F. or 107° F., and the thirst is most intense. This stage 
lasts three or four hours, and often terminates in death. If 
the patient passes into the sweating stage, recovery usually 
takes place. During the intermission the mind is clear, but 
the jaundice continues. Unless the disease is controlled by 
treatment, each succeeding paroxysm becomes more and 
more severe. This variety is incorrectly called pernicious 
bilious remittent fever. 

If the attack is mild, there is only a slight staining of the 
skin, but in that form in which there is an apparent arrest 
of the functions of the liver, the patient may die deeply 
jaundiced, within two or three days after the first discolor- 
ation of the skin has appeared. There is a mild form of 
so-called bilious remittent fever, to which I have already 
referred, in which the febrile movement is constant ; this is 
very different from that form to which I now allude, and 
is better classed under the head of simple remittent. 

These different varieties of pernicious fever, of which I 
have made mention, are almost the only ones ordinarily 
met with in practice. It seems to me that very properly 
they may all be considered under the general head of perni- 
cious fever. 

Remember that all these different varieties depend on 
the same blood-poisoning, differing in its manifestations 
according to the intensity of the poison and the predispos- 
ing atmospheric or septic conditions which may exist in 
the localities where they are developed. 

Differential Diagnosis. — The diagnosis of pernicious 
fever is sometimes very difficult. In determining whether a 
given case is, or is not, one of pernicious fever, the first 
inquiry will be in regard to the character of the prevailing 



160 PERNICIOUS FEVER. 

fever. If pernicious fever is prevailing in the locality, doubt- 
less your diagnosis will be easily made ; if, however, the first 
case in the locality falls under your observation, probably, 
you will find great difficulty in making a diagnosis, and 
this difficulty, to a certain extent, will vary with the type 
of the fever. If, for example, your case belongs to that 
class in which there is a tendency to comas, delirium, etc., 
you may confound it with some form of cerebral disease. 
This form of pernicious fever has been mistaken for cere- 
bral apoplexy, meningitis, and acute uraemia. As a rule, 
it is not difficult to draw the line between apoplexy and 
pernicious fever of the comatose or delirious variety. 

The constant and prominent symptom of apoplexy is 
hemiplegia, which is of rare occurrence in pernicious fever. 
It may occur, but if it does, it is developed slowly. Neither 
coma nor hemiplegia is ever reached suddenly in pernicious 
fever. There is a rise in temperature, rapid pulse, and all 
the phenomena of intense febrile excitement are present 
before the occurrence of either. On the other hand, in 
apoplexy the hemiplegia is of sudden development, attend- 
ed by a slow pulse, irregular, contracted pupils ; or, per- 
haps, one pupil is dilated and the other contracted, and its 
occurrence is preceded by a sudden loss of consciousness, 
and not attended or preceded by high febrile excitement. 
These marked differences between the two diseases will 
lead you to a correct diagnosis. 

As regards mistaking pernicious fever for meningitis, it 
would seem hardly possible for one familiar with both 
diseases to make such a mistake in diagnosis. 

Though in both diseases the patient reaches a condition 
of coma, in meningitis days elapse before the coma is 
reached, and during those days there has been pain in the 
head, photophobia, delirium extending over a considerable 
period of time, and then the coma ; whereas, in pernicious 
fever, within twelve hours the patient reaches his condition 
of coma. Besides, in pernicious fever there will be a his- 
tory, not only of the prevailing type of malarial disease, 
which will indicate its character, but there will precede the 
attack of coma or delirium a distinct malarial paroxysm — 



DIFFERENTIAL DIAGNOSIS. 161 

perhaps two of these paroxysms ; then the patient will 
pass rapidly into a state of coma. In these two diseases 
the condition of the pnpil varies. In meningitis, when the 
patient reaches complete coma, the pnpil will be dilated, 
while in the comatose variety of pernicions fever the pnpil 
may be contracted, dilated, or normal. 

The gastro-enteric and cold or algid variety of pernicious 
fever closely resembles cholera. It may be distinguished 
from it by the character of the primary discharges. You 
may reach a time in pernicious fever when the discharges 
will very closely resemble those of cholera ; but they have 
been preceded by one or two bloody discharges. Then in 
cholera you will have albumen in the urine, the occurrence 
of which is comparatively rare in pernicious fever. Then in 
cholera there are the peculiar surroundings of the patient, 
the prevalence of cholera in the locality, etc. Yet, in a recent 
endemic of choleraic-pernicious fever which prevailed along 
the banks of the lower Mississippi, many prominent phy- 
sicians maintained that it was an epidemic of Asiatic 
cholera. When the endemic is at its height it is almost im- 
possible to make a differential diagnosis between the two 
diseases from the clinical history of the cases ; but, when 
you take the early history of the endemic, at which time 
the cases at their commencement were marked by distinct 
intermittent or remittent paroxysms, then the true charac- 
ter of the disease is very readily determined. If in any 
given case there is still a question whether it is or is not 
one of pernicious fever, this can be determined with posi- 
tiveness by placing some of the patient' s blood under the 
microscope, when, if the case be one of pernicious fever, 
the blood will be found to contain pigment. 

The icteric variety of pernicious fever, which often, in 
mairy of its phenomena, so closely resembles yellow fever, 
may be distinguished from it not only by the history of its 
development, but by the fact that when it prevails as an 
endemic, those are seized with the fever who have been 
longest under the influence of malarial poison, whereas new- 
comers are not usually attacked ; in yellow fever districts 
new-comers are almost certain to contract the disease. 
11 



162 PERNICIOUS FEVER. 

Then the jaundice of yellow fever appears late in the dis- 
ease, while the jaundice of this form of pernicious fever 
conies on early, even before the chill passes away. Again, 
bloody urine is frequently present in this type of pernicious 
fever, while in yellow fever hematuria rarely occurs with- 
out the accompanying evidences of nephritic inflammation. 

It is hardly necessary for me, under the head of differen- 
tial diagnosis, to speak of all the different varieties of per- 
nicious fever, for there is one thing — the presence of free 
pigment in the blood — which settles the question of diag- 
nosis in difficult cases ; this is present in nearly every 
severe case in any form of pernicious fever. 

Whenever any of these types of pernicious fever prevail 
in the region where you are located, you will soon become 
familiar with their peculiar phenomena, and thus be able 
to make an early diagnosis. You must bear in mind that, 
though you have become familiar with one variety of this 
fever, you are by no means prepared to make an early 
diagnosis of any other variety, for the algid and comatose 
varieties differ as widely in the phenomena which attend 
their development as though they were distinct diseases 
and did not depend upon the same poison. 

Prognosis. —In all varieties of pernicious fever the prog- 
nosis is unfavorable. Unless you are able to control the 
disease before the occurrence of the second paroxysm, usu- 
ally the case will terminate fatally. In all cases the prog- 
nosis will depend, to a great degree, upon the character 
of the prevailing endemic or epidemic, as also upon the 
stage of the epidemic, for the ratio of mortality is always 
greater during the early period of an epidemic than during 
its decline. During the latter part of an epidemic you 
may think you are managing your cases better because 
fewer patients die, while the good results are due to the 
fact that the epidemic is on the decline. All observers 
agree that the prognosis is better in every variety of per- 
nicious fever if there are distinct intermissions, however 
short may be their duration. If the paroxysm does not 
last more than twelve hours, and terminates in a distinct 
remission, the prognosis is far better than when one parox- 



PROGNOSIS. 163 

ysm follows another without any distinct remission. If 
the paroxysms are increasing in severity and duration, the 
patient is liable to die in the third or fourth paroxysm. 

Unquestionably the most favorable cases are those of the 
tertian type. Those varieties in which the cases most fre- 
quently terminate fatally are the gastro-enteric and the 
algid ; those in which the cases are most likety to recover 
are the comatose and delirious. 

In every case the prognosis is very much influenced by 
the age and condition of the patient, and by the presence or 
absence of complications. The mortality is greatest among 
the very young and very old, and among the intemperate. 

Patients with pernicious fever may die suddenly during 
a paroxysm, or the paroxysms may be prolonged and run 
into each other, and the patient may finally pass into a 
typhoid or collapsed condition. 

In every variety of pernicious fever you may be aided in 
making a prognosis by remembering what I am about to 
state. 

If the second or third paroxysm is not attended by signs 
of intense visceral congestion, if it declines with profuse 
warm sweats, if it has been preceded by distinct intervals, 
if the urine is free and the appetite early returns, you may 
safely prognosticate a speedy recovery. On the other hand, 
if the second or third paroxysm is protracted and accompa- 
nied by great anxiety and restlessness, with active delirium 
and a tendency to coma, with coldness of the surface ; if 
there is intense pain in the epigastrium, with tingling of the 
surface, and scanty and high-colored urine ; if there is pro- 
fuse vomiting and purging, bleeding at the nose and cold, 
colliquative sweats ; if the pulse becomes small and feeble, 
or the radial pulse is imperceptible, the danger is very great, 
and a fatal issue is almost certain, either immediately or 
in the fourth or fifth paroxysm. Sometimes severe and 
fatal dysentery comes on at the end of a paroxysm ; at 
other times, as the paroxysm subsides, the fever assumes a 
typhoid type, and, after a period of continued fever ranging 
from ten to twelve days, it terminates fatally. 

Treatment. — The expectant plan of treatment, which has 



164 PEENICIOTIS FEVEK. 

been proposed for the management of some of the forms of 
fever which have engaged our attention, cannot be practised 
in the treatment of pernicious fevers. The alarming symp- 
toms crowd upon one another with great rapidity, and it is 
only by prompt and vigorous measures that in the severe 
forms of the disease you will be able to rescue your patient 
from impending death. The issue of life or death often 
hangs upon a single hour. 

Some have proposed, before administering the only spe- 
cific which we possess capable of controlling this disease, 
to produce free purgation by the administration of cathar- 
tics ; others to bleed and freely vomit the patients. If the 
case is one of the gastro-enteric variety, emetics and purga- 
tives are certainly very plainly contra-indicated. It is now 
a well established fact that in all varieties of pernicious 
fever patients do not bear depletion. In India, where the 
most severe forms of pernicious fever prevail, the English 
surgeons are very positive in their testimony upon this point. 
All forms of depletion have been abandoned in the India 
service. 

Although stimulating enemas and friction to the surface 
may act as aids in the management of the algid and deliri- 
ous varieties, they must not be relied upon for any control- 
ling influence which they may have over the disease. 

Those who have had the most extended opportunities for 
testing the different remedies and plans of treatment which 
have been employed in the management of this fever, are 
united in the opinion that quinine and opium are the only 
agents which can be relied upon for controlling every 
variety. 

In the treatment of this fever my own experience is not 
extended ; consequently, I am compelled to give you the 
teachings of those who have written upon this fever. 

So far as I have been able to arrive at conclusions from 
my readings, as well as from my limited experience in the 
treatment of this disease, I am convinced that in the major- 
ity of cases, by the use of opium and quinine hypodermi- 
cally, we may hope to control it, and thus save the life of 
our patient. 



TKEATMENT. 165 

In fact, the hypodermic use of these drugs has inaugu- 
rated a new era in its treatment, for in a large proportion 
of the severer forms it is impossible to get the full effect of 
either of these remedies by the ordinary methods of their 
administration, the usual avenues for their introduction into 
the system being closed. 

The solution of quinine, commonly employed by the 
English surgeons for this purpose, is made by adding one 
hundred and fifty grains of quinine and fifty drops of di- 
lute hydrochloric acid to four ounces of water, and then 
evaporating the solution to two ounces. Of this, thirty 
drops may be administered at each injection. Some add 
carbolic acid to a solution of quinine in dilute sulphuric 
acid ; the carbolic acid is added to prevent abscess at the 
point where the injection is introduced. 

The formula for this solution is as follows : 

$ . Quinia disulphatis grs. 1. 

Acid sulphurici tti. v. 

Acid .carbolici tti. ij. 

Aquae destillat % i. 

M. 

Thirty minims is the quantity usually administered at 
each hypodermic injection ; it represents between three and 
four grains of quinine. I have recently used the following : 

B . Quinia sulph 3 i. 

Hydrobromic acid ... 3 ij. 

Aquae destillat 3 vi. 

M. 

Thirty minims contain four grains of quinine. 

Whatever solution you may use, administer from five to 
seven grains of quinine every hour until the paroxysm has 
passed, then continue its use in three grain doses every 
four hours. 

With the quinine of the first hypodermic injection admin- 
ister one-fourth of a grain of morphia. The morphine should 
be administered with each dose of quinine until the patient 



166 PEEKECTOUS FEVEE. 

is brought fully under its influence, without regard to the 
stage of the paroxysm. 

During the past few years a remedy known as "War- 
burg's Tincture" has been quite extensively employed in 
the treatment of pernicious fever by the India surgeons. 
When this remedy was first employed, its ingredients were 
unknown, and on this account it was not generally made 
use of by the profession. All those who used it claimed 
that it more successfully controlled the fever than opium 
and quinine, or any other remedy that had hitherto been 
employed. The results claimed for it were really astonish- 
ing. 

Recently, the formula for making this tincture has been 
published in the London Lancet. I will give it as pub- 
lished. 

Foemula. 

Warburg 1 s Tincture. 

3- Aloes (Socotr.) iibrom, 
Had. rhei (East India), 
Sem. Angelicse, 

Confect. Damocratis, ana uncias quatuor, 
Had. Helenis (s. Enulse), 
Croci sativi, 
Sem. Fceniculi, 

Cret. prseparat, ana unc. duas. 
Had. Gentianae, 
Rad. Zedoarise, 
Pip. Cubeb., 
Myrrh. Elect., 
Camphorse, 
Bolete laricis, ana unciam. 

Tlie above ingredients to be digested with 500 ounces of 
"proof spirit in a water-bath for twelve hours ; then ex- 
pressed and ten ounces of disulphate of quinia added, the 
mixture to be replaced in the loater-bath until all the qui- 
nia be dissolved. The liquor, when cool, is to be filtered, 
and is then fit for use. 



TKEATMENT. 167 

It will be seen that each half-ounce of the tincture con- 
tains seven and a half grains of quinine. It is recom- 
mended to give half an ounce of this tincture at the onset 
of the paroxysm ; if this does not control it, the same 
quantity must be repeated in four hours. If it cannot be 
retained by the stomach, it may be administered by the 
rectum, in ounce doses every hour. It is claimed that the 
tincture is retained by the stomach when all other remedies 
are rejected. Prof. Maclean says that he has seen the most 
hopeless cases — those manifesting a degree of severity 
which seemed to preclude the possibility of recovery — com- 
mence to convalesce as soon as the patient was brought 
under the influence of this remedy. I will quote Prof. 
Maclean' s rules for its administration : 

"The tincture is administered in the following manner : 
One-half ounce (half of a bottle) is given alone, without 
dilution, after the bowels have been evacuated by any con- 
venient purgative, all drink being withheld ; in three hours 
the other half of the bottle is administered in the same 
way. Soon afterwards, particularly in hot climates, pro- 
fuse, but seldom exhausting, perspiration is produced ; 
this has a strong aromatic odor, which I have often detected 
about the patient and his room on the following day. 
With this there is a rapid decline of temperature, imme- 
diate abatement of frontal headache — in a word, complete 
defervescence, and it seldom happens that a second bottle 
is required. If so, the dose may be repeated as above. In 
very adynamic cases, if the sweating threatens to prove 
exhausting, nourishment in the shape of beef-tea, with the 
addition of Liebig's extract and some wine or brandy of 
good quality, may be required." 

No special rules can be laid down in regard to the admin- 
istration of stimulants in pernicious fever ; the condition of 
the patient must be your guide. They are simply means 
used to aid in carrying a patient over a dangerous period. 
Their continued use in large quantities is objected to by 
those who have had the most extended experience in the 
management of this fever. 

I will repeat in as few words as possible the important 



168 PERNICIOUS FEVER. 

things to be remembered in the treatment of pernicious 
fever. Do not wait for the action of a calomel purge. Do 
not resort to any depleting measures ; patients with this 
fever cannot bear depletion. However mild the paroxysm 
may be, no time should be lost ; bring the patient as rapid- 
ly as possible under the influence of quinine and opium, 
or, if "Warburg's Tincture" is used, administer it in full 
doses as early as possible, and continue its administration 
until convalescence is fully established. 



LECTUEE XV. 



DENGUE FEVER. 



Morb id Anatomy. — Etiology. — Symptoms. — D ifferential 
Diagnosis. — Treatment. — Chronic Malarial Infection. 

Befoee leaving the class of fevers which has just been 
engaging our attention, I wish to say a few words concern- 
ing a fever which, although it may not properly be included 
in the list of malarial fevers, yet it seems to me that it can 
be best considered in this connection. It has received the 
names, dengue, break-bone, and dandy fever. It is neither 
an intermittent nor a remittent fever ; nor is it a pernicious 
fever. It is an acute disease which appears as an epidemic 
in hot climates. It is characterized by a febrile excitement 
remitting in its character, and is accompanied by more or 
less intense arthritic pains, attended by the development of 
a papillary eruption resembling that of measles. 

Mokbid Anatomy. — The morbid anatomy of this variety 
of fever does not differ essentially from that of the severer 
types of malarial fever, except that a cutaneous eruption 
commences on the palms of the hands and extends rapidly 
over the entire body. In most cases, arthritic changes of a 
rheumatic character are present ; usually the external lym- 
phatic glands are somewhat enlarged. 

This disease seems to be an exanthematous malarial 
fever, with a rheumatic or neuralgic element. 

Etiology. — Dengue or break-bone fever may prevail epi- 
demically in well marked malarial districts, or it may be 



170 DENGUE FEVER. 

met with as a sporadic disease. Its infection has been 
carried in clothing from one seaport to another. Some 
claim that the disease depends upon a specific contagion ; 
but its contagious character has not been established. 

The intensity of the malarial poison unquestionably has 
some influence in increasing or lessening the severity of this 
fever. In districts slightly malarial usually its type is mild ; 
but in districts strongly malarial its type is severe. It 
attacks all classes and all ages, rich and poor, black and 
white, the very young and the very old. Occasionally it 
has occurred as the precursor of yellow fever. In 1827 a 
very extended epidemic of this fever prevailed in the West 
Indies ; during the prevalence of this epidemic, the specific 
poison of the disease was transported in clothing and mer- 
chandise to many neighboring seaports. 

Symptoms. — The period of incubation is estimated from 
three to five days. The initiatory symptoms are very sud- 
den in their manifestation, and the development of the fever 
is very rapid. In the majority of cases, the earliest symp- 
toms are headache, photophobia, great restlessness, chilli- 
ness alternating with flashes of heat, and pain in the back, 
limbs, and joints ; the small joints swell, and there is sore- 
ness and stiffness of the muscles. The skin becomes hot 
and dry, and in some instances the temperature reaches 
107° F. The pulse is rapid, ranging from 120 to 140 beats 
per minute. The face is flushed and the eyes red and 
watery. After the fever has continued about twelve hours, 
the pains in the joints become intense, the pain in the back 
shoots down the sciatic nerve, and now nausea, vomiting, 
and pain in the epigastrium are usually the prominent 
symptoms. 

At this stage of the fever the lymphatic glands become 
involved ; the inguinal glands are first affected, then those 
in the axilla and neck ; they increase very rapidly in size, 
and become exceedingly tender. The testicles enlarge, or 
rather the epididymis, and the swelling continues until the 
subsidence of the other symptoms. The active febrile 
excitement continues from twelve hours to three or four 
days, when it subsides, leaving the patient in an exceed- 



SYMPTOMS. 171 

ingly feeble and prostrate condition. Sometimes the fever 
abates suddenly, with the occurrence of critical symptoms 
as in relapsing fever, such as profuse sweats, diarrhoea, or 
epistaxis. Then the patient is in a passive condition for 
two or three days, and passes into the period of remission. 
The pains now become less, the glandular swellings diminish, 
there is less of febrile excitement, but it does not entirely 
subside. After two or three days a second paroxysm occurs, 
and the fever returns. About the same time intervenes 
between the first and second paroxysm as occurs between 
the first and second paroxysm of relapsing fever. When 
the fever returns it is more intense, the pain in the joints is 
more severe, and finally, when the fever has reached its 
height and the pain is most intense, usually on the fifth or 
sixth day, an eruption makes its appearance. It first ap- 
pears upon the palms of the hands, then upon the neck; 
soon it extends downward and is seen upon the chest, and 
finally spreads over the entire body. Usually it is papil- 
lary in character and very closely resembles the eruption 
of scarlatina. In most cases, as soon as the eruption is 
developed, the febrile symptoms subside and the patient 
goes on to convalescence. 

From the intense arthritic pains accompanying the papil- 
lary eruption, and from the glandular swellings, you will be 
able to recognize this peculiar type of fever. As the second 
paroxysm of fever subsides, the patient is left with stiffness 
and soreness of the joints, which sometimes does not pass 
away for weeks. Occasionally the disease assumes a ty- 
phoid type, the tongue becomes coated with a dark brown 
coating, the gums become red and spongy, the pulse is slow 
and feeble, and the surface is covered with a cold sweat. 
As soon as the eruption appears, the patient is generally 
free from fever, and passes on to a rapid and complete con- 
valescence. 

In very severe cases the pain in the testicles will con- 
tinue after the subsidence of the fever, and a serous effusion 
will take place into the tunica vaginalis. The joints will 
remain painful and flabby. There will be extreme nervous- 
ness and anxiety. The heart's action will be intermittent, 



172 DENGUE FEVER. 

and the lymphatic glands, which have been enlarged, form 
indurated tumors ; they very rarely suppurate. The dura- 
tion of this fever varies with the period of remission. Its 
average duration is about eight days. 

In those epidemics where there is an absence of articular 
pains, the mucous membrane of the mouth and throat be- 
comes involved. 

The course of the disease may be divided into periods. 
First, that of febrile exacerbation, lasting two or three days, 
then an intermission of two or three days, then a second 
febrile exacerbation which lasts two or three days, then 
convalescence begins. 

Differential Diagnosis. — This fever may be confound- 
ed with rheumatism, or with remittent fever. In some of 
its phenomena it closely resembles relapsing fever. 

It may be distinguished from remittent fever by the per- 
sistency of the rheumatic and neuralgic pains, by the cuta- 
neous eruption, and by the length of the remission. 

It may be distinguished from rheumatism, as it prevails 
epidemically, and a period of febrile excitement precedes 
the arthritic phenomena. It may be distinguished from 
relapsing fever by the eruption and by the character of the 
remissions. 

Prognosis. — The prognosis is always favorable, although 
the symptoms which attend its development may be alarm- 
ingly severe. The prognosis is only unfavorable when it 
occurs in the very aged or in feeble infants. 

Treatment. — This fever always runs a definite course, 
and its treatment is the symptomatic treatment of fever, 
combined with well recognized anti-rheumatic remedies. 

It is claimed that emetics and free purgation diminish 
the intensity of the fever. A favorite combination is ipecac, 
calomel, and colchicum — these to be administered every 
night in cathartic doses. Calomel should never be admin- 
istered alone, nor in combination with other drugs, if its spe- 
cific effect is likely to be produced. 

The administration of colchicum with spirits of nitre and 
nitrate of potash, in such proportion that profuse diapho- 
resis may be produced, in connection with the administra- 



TREATMENT. 173 

fcion of effervescing draughts, will usually afford relief from 
the pain in the head and limbs. Should the arthritic pains 
still be felt, opium may be administered in sufficient quan- 
tity to afford relief. 

During the remission the bowels should be kept freely 
open with saline purgatives, and quinine combined with an 
alkali should be given at stated intervals. Narcotics may 
be given in small doses to produce sleep, should the patient 
be wakeful. By the employment of these measures a return 
of fever may be prevented and the arthritic pains will grad- 
ually subside. If this plan is pursued, should the fever 
return, it will be mild in character, attended by little con- 
stitutional disturbance. The weakness and exhaustion 
which attend convalescence may be combated by the free 
use of wine or malt liquors. 

The diet should be most nutritious. Nourishment should 
be administered at stated intervals, during the night as well 
as during the day. 

The lymphatic enlargement, especially in the inguinal 
region, should be treated locally with iodine. 

Citrate of iron and quinine will be found of great service 
during the convalescing period. If a single joint remains 
swollen and tender for a considerable period after the sub- 
sidence of the fever, the occasional application of a blister 
is recommended. In some epidemics, relapses after an 
interval of two or three weeks have been of frequent occur- 
rence. They run a milder course than the primary fever. 
The relapses more closely resemble an attack of articular 
rheumatism than they do the primary fever. Quinine is 
said to furnish great protection against a relapse. 

CHRONIC MALARIAL INFECTION. 

There is still another form of malarial manifestation 
closely connected with the subject which has been engaging 
our attention, of which I will briefly speak. It has been 
termed malarial cachexia, or better, chronic malarial infec- 
tion. I do not include it in the list of malarial fevers, 
although it may be a sequela of any form of acute malarial 



174 CHRONIC MALARIAL INFECTIONS. 

disease. It may be developed in those who have never 
suffered from any form of malarial fever, but who have 
resided for some time in a malarial district. For instance, 
a person who has had repeated attacks of intermittent or 
remittent fever, and has become exceedingly anaemic, with 
an enlarged spleen and enlarged liver, may be regarded as 
in a condition of chronic malarial cachexia, and is in a 
condition to present the phenomena of chronic malarial 
infection. Again, a person who has never had a distinct 
paroxysm of malarial fever, but who has lived for some 
time under malarial influences, the malarial poisoning never 
having been intense, becomes anaemic with enlarged spleen 
and liver, and presents the phenomena of chronic malarial 
infection. 

Morbid Anatomy. — The morbid anatomy of chronic 
malarial infection does not differ from that of the severer 
types of malarial fever, except in the more advanced stages 
of the tissue-changes. For instance, the spleen is often ten 
or twelve times its normal size, tough, firm, and resistent. 
Its surface is uneven, its capsule enormously thickened, and 
more or less adherent to the adjacent organs. Its substance 
is rich in pigment matter, and presents the minute changes 
either of simple hyperplasia or amyloid degeneration. Simi- 
lar tissue-changes take place in the liver and kidneys. In 
some instances the muscular tissue of the heart undergoes 
fatty or amyloid degenerative changes. (Edema of the sub- 
cutaneous cellular tissue, and an accumulation of fluid in 
the serous cavities, are common attendants of chronic mala- 
rial cachexia. 

Etiology. — It is unnecessary to repeat what I have al- 
ready said in regard to the causes of malarial infection. 
It may be the result of prolonged exposure in a district 
only slightly malarial, or of a short exposure in a district 
strongly malarial. 

Symptoms. — Those who are the subjects of chronic ma- 
larial infection complain of vertigo, ringing in the ears, loss 
of memory, disturbance of the sight, loss of appetite, 
nausea, dyspeptic symptoms, and pain and oppression in 
the epigastrium. The bowels are rarely constipated ; often 



SYMPTOMS. 175 

In the morning diarrhoea is present. The sleep is dis- 
turbed ; it may be profound, but it is unrefreshing. The 
patient awakes in the morning with a confused feeling about 
the head and a general feeling of discomfort. Some com- 
plain of pains in the back and loins and along the sciatic 
nerve ; others complain of pain and tenderness in the 
joints and stiffness of the muscles of the limbs and back ; 
they become easily fatigued on exertion, complain of short- 
ness of breath, and have palpitation of the heart. 

The nervous system seems to suffer most severely. One 
of the most common nervous manifestations is local anes- 
thesia, which usually shows itself upon the outer surface of 
the thighs. Not unfrequently numbness of the arms and 
fingers, and tickling and burning of the feet are complained 
of, and a patient will consult you, thinking he is about to 
have an attack of paralysis. Last year a prominent lawyer 
of this city, suffering from chronic malarial infection, came 
under my observation. Sometimes he would continue an 
argument in court half an hour after there was a partial 
loss of consciousness ; he would afterwards ask his pro- 
fessional brethren what he had said while in this state. 

Hemiplegia sometimes occurs. I remember one case in 
which there was complete loss of power over the right arm 
and leg, yet no facial paralysis. This patient had never 
had a paroxysm of malarial fever, and for that reason the 
possibility of malarial infection had been excluded. Simi- 
lar manifestations of chronic malarial infection quite fre- 
quently occur in those who have never had a distinct ma- 
larial paroxysm. — 

You may have a form of chronic malarial infection unat- 
tended by any nervous manifestations. This form shows 
itself in catarrhal inflammations affecting the mucous mem- 
brane of the stomach, intestines, and bronchial tubes. 
Patients have a form of bronchitis which is really a chronic 
malarial affection. 

A gastro-enteritis, in which there is marked interference 
with digestion, may be developed as the result of chronic 
malarial infection. If this is treated with the ordinary 
remedies for dyspepsia, no good result is accomplished, 



176 CHRONIC MALARIAL INFECTIONS. 

while a few doses of quinine will establish the diagnosis 
and relieve the patient. 

The chronic catarrh of the intestines resulting from 
chronic malarial poisoning may give rise to a troublesome 
diarrhoea, which will assume all the characteristics of 
chronic diarrhoea. As I have already stated, anaemia is a 
very common result of long-continued malarial poisoning, 
and palpitation of the heart is a very frequent and some- 
times distressing accompaniment of such ansemia. With 
many persons it gives rise to temporary attacks of melan- 
cholia and hypochondriasis. Such persons imagine they 
have disease of the heart, or kidney, or spine, etc. In some 
cases the hypochondriasis assumes a suicidal character, or, 
at least, the individual threatens self-destruction, though I 
never knew one to do any harm to himself during the 
attack. 
~— Another nervous manifestation of chronic malarial infec- 
tion is neuralgia. Certain nerve-trunks or their roots seem 
to be directly affected, while the nerve-centre connected 
with the affected nerve- trunks escapes. The first branch 
of the fifth nerve is most liable to be affected in malarial 
neuralgia. This neuralgia follows a periodic course. Per- 
sons over forty are most liable to be affected by it. Usual- 
ly the nerve-trunks first affected are the ones involved in 
successive attacks ; for instance, if a certain intercostal 
nerve is the seat of the primary neuralgic paroxysm, at 
each subsequent attack this particular nerve will be the 
f seat of the neuralgia. + 

In some instances chronic malarial infection manifests 
itself by hemorrhages from the mucous surfaces, such as 
epistaxis, hsematemesis, hematuria, etc. The most trouble- 
some case of menorrhagia (occurring independent of a 
mechanical cause) which has come under my observation 
recovered after the administration of large doses of quinine, 
when all the remedies ordinarily employed in such cases 
had failed to produce the desired result. 

Recently a patient came under my observation who was 
in a scorbutic condition, with spongy gums, and with large 
purpuric spots scattered over the surface of the body ; his 



DIFFERENTIAL DIAGNOSIS. 177 

surroundings and the effect produced by anti-malarial 
treatment left little doubt in my mind but that chronic 
malarial infection was the cause of all the scorbutic and 
purpuric manifestations. 

Differential Diagnosis. — The first question that now 
arises is, how can you decide whether these manifestations 
to which I have referred are malarial or non-malarial \ In 
the majority of cases there will be some enlargement of the 
spleen — it may be only very slight. There is not neces- 
sarily any rise in temperature. The manifestations will be 
more or less paroxysmal. If the patient has localized anaes- 
thesia or hj^persesthesia, it will be found to be more severe 
some time in the morning or evening. If he has lost power 
over one portion of the body, he will find that the loss of 
power is more marked at a certain period of the day. The 
patient may not observe this, unless you direct his atten- 
tion to the fact ; then he will readily recognize it. It is for 
you to elicit the fact by a careful examination. 

You will also find in the severer cases of chronic malarial 
infection, when there is hemiplegia or some structural 
change affecting the mucous membrane of the stomach, 
intestines, bronchial tubes, etc., that there are also evi- 
dences of pigmentation of the tissues. Free pigment is 
frequently found in the blood. It is not found in those 
cases where the malarial posioning is slight, where it is 
only sufficient to produce ringing in the ears and slight 
attacks of neuralgia, perhaps accompanied by slight gastro- 
intestinal catarrh ; but when the malarial poisoning is 
sufficiently intense to cause temporary loss of consciousness, 
hemiplegia, or any other of the severer manifestations 
already alluded to, even though there has been no distinct 
malarial paroxysm, an examination of the blood will almost 
certainly give evidence of free pigmentation. 

The diagnosis of chronic malarial infection, to a certain 
extent, depends upon the circumstances which attend its 
development. If the individual has repeatedly suffered 
from malarial fever paroxysms, or if he has resided for some 
time in a malarial district, even though he may not have 
had a distinct malarial paroxysm, though none of the 
12 



178 CHRONIC MALAEIAL INFECTION. 

phenomena to which I have just referred have been de- 
veloped, and though that peculiar malarial cachexia which 
is so characteristic of malarial poisoning is not present, yet 
it is alwaj^s well to carefully consider the question of 
malarial infection. 

While the manifestations of chronic malarial poisoning 
may be called legion — and in many instances they very 
closely simulate the phenomena of other diseases — still, with 
a history of possible malarial exposure, by a system of ex- 
clusion you reach the fact that the patient is suffering from 
some form of blood poisoning. When you have reached 
that conclusion you are able readily to determine the nature 
of such poisoning. In very doubtful cases you may arrive 
at a diagnosis, or perhaps confirm an uncertain diagnosis 
by treatment, in the same way in which we sometimes 
7^ detect syphilitic infection by the effects of treatment. 7- 

Prognosis. — The prognosis in chronic malarial infection 
depends upon the severity of its manifestations. The 
degree of enlargement of the spleen and liver is a reliable 
indication of its severity. 

When the symptoms are mild and the spleen is but 
slightly enlarged, and when neither ascites nor oedema of 
the lower extremities is present, the prognosis is generally 
good. If the patient is very anaemic, the spleen very 
greatly enlarged, and the area of hepatic dulness very 
much increased, the prognosis is unfavorable. When dis- 
tinct tumors can be detected in the spleen and liver, they 
indicate an exceedingly grave form of malarial infection ; 
if the tumors are large, they can rarely be reduced. If the 
individual in whom these tumors are found removes from 
a malarial district, a long time may elapse before they ap- 
parently very much interfere with his health and comfort. 

You must take into consideration the possibility of your 
patient being able to take up his permanent residence in a 
non-malarious region, before you make a prognosis in any 
given case. 

So long as such a patient is under malarial influences, 
however slightly malarial they may be, the progress of 
the disease cannot be permanently arrested ; and when the 



TREATMENT. 179 

manifestations of the graver forms of malarial infection are 
present, there is little prospect that the disease can be tem- 
porarily relieved so long as the patient remains in the 
malarial district. 

Treatment. — The first and most important thing to be 
accomplished in the treatment of chronic malarial infection 
is the removal of the individual from a malarious district 
to a high, warm, mountainous region. It is of the great- 
est importance that all exposure to wet and cold, and the 
damp air of the evenings and nights, should be avoided ; 
the sleeping apartments must be dry and airy, and flannel 
should be worn next to the skin. 

So long as the thermometer shows even a slight febrile 
movement, quinine must be given in full doses. If ansemia 
is present, which is usually the case, iron must be combined 
with the quinine, and administered immediately before or 
after taking food. 

In those cases in which the spleen and liver are very much 
enlarged, when no febrile excitement is present, iodide of 
iron combined with cod-liver oil will be found of great 
service. 

It is claimed by some that muriate of ammonia has a 
very beneficial effect in this class of cases, but my own 
experience does not lead me to favor its use. 

If the bowels are constipated, aloes or rhubarb should be 
given in connection with some of the chlorine mineral waters. 
In those cases in which the measures already referred to 
fail to produce any improvement or afford any permanent 
relief, arsenic may be resorted to, but the effects of the 
drug must be carefully watched, and on the appearance of 
oedema or of gastric disturbance, it must be promptly dis- 
continued. It must be borne in mind that the use of all 
these therapeutic agents is not sufficient ; proper attention 
must be paid to hygienic measures. 

The neuralgias which are such frequent manifestations of 
this infection are best treated by combining a full dose 
of opium with large doses of quinine. If paralysis is a 
manifestation of the malarial poisoning, strychnine, iron, 
and quinine may be combined in its treatment, in con- 



180 CHRONIC MALARIAL INFECTION". 

nection with cold douches and friction to the paralyzed 
limbs. 

A most nutritious diet and a liberal use of good wine is 
indicated in all cases of chronic malarial infection. The 
daily use of brandy in small quantities is of great service. 

I will add a few words in regard to the use of quinine in 
this class of cases. I am convinced that the indiscriminate 
use of this drug often does harm. After fairly testing its 
effects, if no relief is obtained, its use should be discon- 
tinued for a time, or at least until the beneficial effect of a 
removal from a malarial district is tried, or until, by the use 
of mild cathartics and the daily administration of cod-liver 
oil and iron, the patient is in a condition to be benefited by 
it. Quinine seems to have no effect upon many persons 
suffering from the severe manifestations of this infection, so 
long as they remain in a malarial district. It is of the 
greatest importance that you should early make yourself 
familiar with the condition in which quinine is indicated 
in the treatment of this class of affections. Let me impress 
upon you the importance of avoiding depressing remedies 
in all forms of chronic malarial infection. Drastic cathar- 
tics, exhausting diaphoretics, and all other depressing 
remedies must be carefully avoided. They do great harm 
by exhausting the already enfeebled vital powers. Espe- 
cially is this true in regard to the free use of mercurials, 
which are so commonly resorted to in their management. 
Unquestionably, an occasional cathartic dose of calomel is 
of service, but the administration of small doses repeated 
after short intervals, in order to produce the constitutional 
effects of the drug, will always be followed by the more 
serious manifestations of the malarial infection. 

The exhausted system of this class of patients needs rest, 
concentrated nutrition, and the supporting influence of a 
change of climate and tonics. 



LECTURE XVI 



TYPHO-MALARIAL FEVER. 

Introduction. — Morbid Anatomy. — Etiology. — Symptoms. 

I shall this morning commence the history of typho-ma- 
larial fever. I have included this fever in the list of the 
malarial fevers, although ifc is not altogether malarial in its 
origin ; malarial poison, however, is so essential to its de- 
velopment that it may very properly be regarded as one of 
the malarial fevers. 

As its name indicates, it has many elements in common 
with typhoid, and many which ally it to remittent fever. 
To the term " typho-malarial " different significations have 
been given by different observers. By one class the term 
has been employed to indicate the presence of malaria, and 
also the specific poison which produces typhoid fever. 

By another class of observers the term has been employed 
to indicate the presence of malaria, and also a septic poison 
which differs from the specific poison that gives rise to ty- 
phoid fever. 

There is still another class of observers who doubt the 
existence of such a form of fever, and regard the so-called 
typhoid element as nothing more than a "typhoid con- 
dition," liable to be developed in connection with remittent 
fever, as well as many other diseases. 

The term typho-malarial is a convenient one for the first 
class of observers, and is one which can be employed by 
them without confusion ; whereas, for the second class of 
observers, it is exceedingly inconvenient, giving rise to con- 



182 TYPHO-MALAKIAL FEVER. 

fusion, because it does not embrace the views held by them 
regarding the etiology of the disease. 

But we have the term, and I shall employ it as one denot- 
ing a fever which is produced by the combined action of a 
septic and a malarial poison. As far as possible I shall 
use the word septic when speaking of the poisons which 
are associated in the production of the disease, and the 
term typhoid will be reserved for that peculiar condition 
known as the " typhoid condition," and for the specific dis- 
ease known as typhoid fever. You will meet with some 
cases of typho-malarial fever in which the septic element 
predominates, and others in which the malarial element is 
predominant. The preponderance of the leading features 
of the one or the other of these two forms of fever will 
enable you to determine with a good degree of certainty 
the course, prognosis, and treatment of each individual case. 
The distinguishing lines, however, between these two ele- 
ments are not always sharply defined, but almost impercep- 
tibly the symptoms dependent upon one poison become 
mingled with those developed by the other. Both of these 
elements may be modified in their manner of development 
and in their morbid anatomy, by the occurrence of various 
intercurrent complications, such as scurvy, pneumonia, etc. 

Morbid Anatomy. — The changes which take place in the 
constituents of the blood in typho-malarial fever, so far as 
we are yet able to determine, are similar to those which 
occur in typhoid fever, combined with those which are char- 
acteristic of malarial fever ; the presence of free pigment 
granules in the blood is often a strong point in its differen- 
tial diagnosis. 

In connection with these blood changes, there are more or 
less parenchymatous changes in the internal organs similar 
to those met with in other forms of fever and in acute in- 
fectious diseases. The liver is increased in size, and its cut 
surface presents an appearance which closely resembles that 
known as nutmeg liver. Sometimes it presents the peculiar 
bronzed color of the liver in remittent fever ; at other times 
it very closely resembles the liver of yellow fever. A mi- 
croscopical examination shows free fat and more or less 



MORBID ANATOMY. 183 

brown pigment granules in the hepatic cells. In most cases 
of this fever the spleen is enlarged, softened, and of an al- 
most black color. The Malpighian bodies are prominent, 
and present the appearance on the torn surface of the spleen 
of little tumors, which vary in size from a pin's head to that 
of a pea. The organ is rarely as much enlarged or softened 
as in typhoid or remittent fevers. It is always the seat of 
more or less pigmentation. 

'No uniform change will be noticed in the kidneys, except 
that of hyperemia, which will be most marked in their cor- 
tical substance. 

The lungs at their most depending portion are the seat of 
more or less extensive hypostatic congestion. Splenization 
of the lungs is not as frequently present as in typhoid fever. 

The heart is pale and flabby, Its muscular fibres are the 
seat of a granular degeneration similar to that which takes 
place in the heart in typhoid fever. Exsanguinated clots 
more or less firm may be found in its cavities, but they 
have nothing peculiar about them. They closely resemble 
those found in persons who have died from failure of heart 
power. They are rarely, if ever, the direct cause of death. 
My own examinations of the intestinal lesions of this fever 
have led me to adopt, for the most part, the descriptions 
which have been published by Dr. J. J. Woodward, of the 
U. S. A. In fact, Dr. Woodward's investigations in this 
direction may be regarded as exhaustive. That the intes- 
tinal changes of typho-malarial fever very closely resemble 
those of typhoid fever there can be no question ; by some 
they have been regarded as identical, but I think, if we very 
carefully observe them, some very marked differences can 
be recognized ; especially if we attempt to divide the stages 
of their development into periods so as to correspond to the 
days and weeks of the fever, as is possible with the intes^ 
tinal changes of typhoid fever. 

As in typhoid fever, the principal and almost constant 
changes are to be found in and around the closed follicles 
of the intestinal tract. These changes are made manifest) 
by the gradual enlargement of the follicles, which, as they 
enlarge, become more or less pigmented. 



184 TYPHO-MALARIAL FEVER. 

At the post-mortem examination of one who has died of 
this fever, you will usually find these glands in all stages 
of this pathological process, from slight enlargement and 
softening to ulceration of the entire follicle. The summit 
of the enlarged follicle is the first seat of the ulcer. These 
ulcers may involve a single follicle, or they may invade the 
adjacent mucous membrane, and produce ulcers from one- 
half an inch to an inch in diameter. The largest and most 
extensive ulcerations are to be found in the ileum and in- 
volving the Peyerian patches. The edges of these ulcers 
are irregular and everted ; their base is usually of a grayish 
color, often mottled with black points. These ulcers may 
extend into the submucous tissue and involve the muscular 
coat of the intestine, and even perforate the peritoneal 
covering of the intestines. 

In the earlier stages there is little to distinguish these 
intestinal changes from similar ones which develop in ty- 
phoid fever, except, perhaps, the tendency to the deposit of 
black pigment in the enlarged follicles. In a later stage, 
certain peculiarities are present, which are often sufficiently 
distinctive to designate the case as one of typho-malarial 
fever. For instance, in typho-malarial fever there is a grad- 
ual elevation of the mucous membrane surrounding the 
enlarged follicles, which, if ulcers exist on their edges, 
reaches a thickness of from three to six lines. 

These ulcers differ from those of typhoid fever in that 
the enlarged patch rises abruptly from the mucous mem- 
brane, and in such a manner that the summit is often 
larger than the constricting base. Besides, the umbilical 
depression so often seen in ordinary typhoid patches prior 
to ulceration is rarely observed in typho-malarial fever. 
As I have already stated, the ulcers in typho-malarial fever 
present ragged, irregular edges, which are usually exten- 
sively undermined, in consequence of the erosions ex- 
tending into the submucous tissue, rather than into the 
glandular layer of the mucous membrane. This undermin- 
ing of the edges is much more extensive than in typhoid 
ulcers. 

The mucous membrane between the follicles presents the 



MORBID ANATOMY. 185 

ordinary appearance of catarrhal inflammation, namely, 
there is more or less congestion, tumefaction, and in the 
later stages thickening and softening of its tissue. 

The minute anatomical changes which attend the develop- 
ment of these intestinal lesions, as determined by the micro- 
scope, do not essentially differ from those which I have 
already described as occurring in typhoid fever, except that 
they have no regular stage of development marked by days 
and weeks, the processes are slower in their development, 
and the presence of pigment in the enlarged and ulcerating 
follicles stamp it as depending upon an essentially different 
exciting cause. Hence, although the intestinal lesions of 
this fever very closely resemble those of typhoid, they are 
not identical, but evidently belong to another type of dis- 
ease. Undoubtedly, there are cases in each of these two 
forms of fever between which, by the intestinal lesions alone, 
it is impossible to draw the line of distinction ; but in typi- 
cal cases this is easily done. 

Intestinal perforation, and a consequent peritonitis, the 
result of the intestinal ulceration, may occur in typho- 
malarial fever, but you will rarely meet with such an acci- 
dent. Usually the mesenteric glands are more or less en- 
larged, and in the advanced stages of the disease more or 
less softened. They are of a livid color, and more or less 
pigmented. The greatest enlargement of these glands will 
be found in that portion of the mesentery which corresponds 
to the most extensive and advanced intestinal changes. 

The principal changes in the structure of the glands are 
similar to those which occur in a purely inflammatory 
process. 

Occasionally, minute ulcers are met with in the mucous 
membrane of the stomach and large intestines, and the mu- 
cous membrane of the stomach is not unfrequently very 
greatly softened, and the mucous membrane of the large 
intestine, if there have been any manifestations of scurvy 
during the progress of the fever, will be thickened and 
softened, perhaps extensively ulcerated, presenting an ap- 
pearance, in some instances, closely resembling those found 
after death in chronic malarial dysentery. While, there- 



186 TYPIIO-MALAEIAL FEVER. 

fore, we find no pathological lesions which can be regarded 
as characteristic of this type of fever, and while the lesions 
which we do find very closely resemble those of typhoid 
fever on the one hand, and remittent fever on the other, 
still there are marked differences which distinguish it from 
either of these fevers sufficiently to stamp it as a distinct 
type of fever. 

Etiology. — It is difficult to determine the true etiology 
of typho-malarial fever. That malarial poison is necessary 
for its development there can be no question. It is equally 
certain that some other poison besides malaria is in opera- 
tion whenever this fever prevails. That this poison is not 
the specific poison of typhoid fever is apparent from the 
fact that its development and spread, as far as can be de- 
termined, is in no way connected with the excrements of 
one suffering from this fever. 

There are a few facts connected with its development 
which are now well established : 

First. — It is only met with in malarial districts. 

Second. — In the majority of instances, when this fever has 
prevailed, its development has been preceded or attended 
by marked, and easily recognized, anti-hygienic conditions, 
such as overcrowding, bad sewerage, and other conditions 
favorable to the development of septic poison. 

Third. — That it is a non-contagious disease, and is never 
propagated from the affected to the healthy, either directly 
by personal contagion, or indirectly by morbid excretions. 

Fourth. — In its morbid anatomy and symptomatology it 
is a combination of two well recognized forms of fever. The 
special symptoms and lesions of one or the other of these 
fevers stamp its character, and indicate its alliance to a ma- 
larial or septic type of fever. 

In large cities, in which malarial diseases are prevalent, 
sewer gases seem to furnish the septic element which is so 
necessary for the development of this type of fever. The 
history of disease in our own city during the past few years 
furnishes striking examples of the combination of these two 
poisons in developing a type of fever which it seems to me 
must be classed under this head. 



SYMPTOMS. 187 

Symptoms. — It is even more difficult to present a typical 
picture of this fever than of typhoid. To give you even 
an outline of its symptoms which shall be approximately 
true of all, or even the majority of cases, is impossible. Its 
clinical history varies as the malarial or septic element pre- 
dominates. Besides, there are a large number of cases in 
which neither of these elements can be said to predominate, 
for the patient almost insensibly passes from a malarial into 
a typhoid condition. There are also certain anti-hygienic 
conditions which may be present, which give to the fever an 
unusual and peculiar type. For example, when those con- 
ditions exist which favor the development of scurvy, if 
typho-malarial fever is prevailing, as the patient enters 
upon the second week of the fever the scorbutic pheno- 
mena will become prominent. 

At times the dysenteric element may be engrafted on this 
fever, which shall greatly modify its course, and lead to a 
train of symptoms and morbid changes which shall very 
closely ally it to epidemic dysentery. 

The course of this fever may also be greatly modified by 
certain local complications which are especially liable to 
occur during the second or third week. The presence of 
any of these conditions will greatly change its clinical 
history, but the phenomena which attend its early develop- 
ment will always be sufficient to determine its true character. 

In considering in detail the symptoms of this fever, I will 
first describe that class of cases in which the malarial ele- 
ment is predominant. 

This type of fever is usually ushered in by a distinct chill . 
In some instances no premonitory symptoms are present, in 
other cases the chill is preceded by wandering pains in the 
limbs and back, headache, loss of appetite, and a feeling of 
great exhaustion. In a large proportion of cases, in the 
early stage, the countenance has a peculiar waxy, clay- 
colored, or yellowish tinge. The chill varies in duration 
from half an hour to an hour, and in character closely 
resembles the chill of simple remittent fever. It is imme- 
diately followed by active febrile symptoms, the tempera 
ture rising in a few hours to 103° F. or 104° F. The pulse 



188 TYPHO-MALAEIAL FEVEE. 

reaches 100, and is full and forcible. The excretions are all 
checked, and there is mental disturbance and sometimes 
delirium. When once established, the fever pursues a 
variable course. At its onset, and for the first few days, its 
phenomena often closely resemble those of simple remittent 
fever, though the remissions are never so well defined as in 
remittent, and there is at the very onset of the fever an 
amount of intestinal disturbance which is rarely present in 
simple remittent. The existence of abdominal tenderness, 
especially in the right iliac fossa, is a strong point in the 
differential diagnosis of typho -malarial and simple remit- 
tent fever in favor of the former. As the temperature rises, 
nausea, vomiting, and epigastric tenderness are present in 
a greater or less degree. These gastric symptoms bear a 
close resemblance to those which attend the development of 
remittent fever, while the intestinal and abdominal symp- 
toms are similar to those of typhoid fever. Diarrhoea may 
precede the chill ; in most cases it is- present during the 
period of fever. At first the tongue presents a pale, flabby 
appearance, with a smooth surface ; soon it becomes covered 
with a white or yellowish- white coating ; later it becomes red 
and the coating becomes brownish ; in severe cases it may 
suddenly become clean, red and shining, and sordes may 
collect upon the teeth and lips. 

In those cases in which a scorbutic element exists, the 
tongue is enlarged, pale, and flabby, its surface smooth 
and covered with a white fnr, which is thickest on its edges, 
the gums are swollen and present the characteristic appear- 
ance of scurvy. 

In those cases in which a dysenteric element is present as 
the fever develops the dysenteric symptoms become promi- 
nent, the discharges from the bowels are blood-stained and 
watery. The tongue soon becomes dry and brown, and the 
patient shows signs of extreme exhaustion, with few of the 
gastric symptoms which are usually so well marked in the 
early period of the fever. 

Throughout the whole course of the disease there is a 
marked tendency to periodicity, the exacerbations usually 
assuming a tertian type. In fatal cases, as the patient 



SYMPTOMS. 189 

reaches the second or third week, the symptoms are very 
like those of fatal typhoid fever : the prostration becomes 
more and more complete, the pulse reaches 130 or 140, is 
feeble and irregular, the patient gradually passes into a 
state of stupor and coma, involuntary evacuations take 
place, and death ensues. 

In cases that recover, symptoms of amendment may be 
noticed between the tenth and twentieth days. The tongue 
begins to become clean, the abdominal symptoms subside, 
the pulse becomes less frequent and fuller, the disturbance 
of the nervous system disappears, the appetite gradually 
returns, and the patient enters upon a tedious convales- 
cence, which is attended by more or less diarrhoea, mental 
stupor, cardiac irritability, and a slow return of mental and 
physical vigor. 

The train of symptoms thus briefly sketched may be 
greatly modified by a variety of complications. Not unfre- 
quently pulmonary complications develop during its second 
week, and so change its phenomena that the fever element 
may be overlooked and the pulmonary element alone engage 
the attention of the physician. 

Suppurative inflammation of the cervical and inguinal 
glands sometimes complicates this type of fever, and leads 
one to the mistake of regarding it as purely a suppurative 
fever. 

Again, scurvy under certain anti-hygienic conditions may 
so modify the usual phenomena of typho-malarial fever, 
that it has led some to regard this fever when developed 
under such circumstances as an entirely new type of fever, 
entirely losing sight of its malarial element, and classing it 
among the infectious fevers. The scorbutic element in this 
class of cases is developed in connection with the malarial 
exposure. 



V 



LECTURE XVII 



TYPHO-MALARIAL FEVER. 

Symptoms (continued) . — Differential Diagnosis . — Progno- 
sis. — Treatment. 

I have mentioned the prominent symptoms which attend 
the development of that type of typho-malarial fever in 
which the malarial element predominates, and will now 
speak of those present in the septic type of this fever. 
Although the premonitory symptoms of this type, such as 
lassitude, headache, pains in the back and limbs, resemble 
those of typical typhoid fever, either a distinct chill or a 
complete intermittent or remittent paroxysm ushers in the 
febrile symptoms. 

The rise in temperature following the ushering-in chill has 
no typical range ; in some cases the rise is gradual, not 
reaching its maximum before the middle of the second week ; 
in other cases the rise is sudden, reaching 104° F. or 105° F. 
within twenty-four hours after the occurrence of the chill. 
Throughout the whole course of the fever the same tendency 
to periodicity exists which was noticed in the malarial type 
of this fever. 

In typhoid fever, during the first week, there are indis- 
tinct forenoon remissions and afternoon exacerbations, but 
in this fever the remissions are well marked, especially on 
every second or third day, causing the fever to assume a 
more or less distinct tertian or quartan type. One of the 
earliest symptoms is well-marked hepatic tenderness ; with 



SYMPTOMS. 191 

the hepatic tenderness there is enlargement of the spleen, 
which, as the fever progresses, reaches a much larger size 
than is ordinarily met with in typhoid fever. During the 
first week the pulse is full and rarely more than 100 beats 
per minute, but during the second and third weeks it is 
small and compressible, and in severe cases intermittent, 
and ranges from 110 to 130 per minute. The appearance of 
the tongue varies with the period of the fever. At first it 
is swollen, with red projecting papillae, and has a light 
white coating. As the typhoid condition becomes more 
prominent its appearance changes ; it becomes dry and 
brown, and frequently the brown coating cracks, and 
fissures are formed in the mucous membrane underneath. 
Should the tongue become moist and begin to clean, you 
may regard convalescence as established. The coating is 
removed in two ways, either gradually from the edges to the 
centre, or it is thrown off in flakes. In the latter case, after 
the removal of the coating, the tongue assumes a beefy 
red appearance, and after a short time may again become 
brown and dry. Under such circumstances there will be a 
renewal of the fever-symptoms. 

After the fever has continued a few days the surface 
becomes dry and harsh, and the skin assumes a bronzed 
hue, which is quite characteristic of this fever ; sometimes, 
instead of this bronzed hue of the surface, there is well- 
marked jaundice. 

The changes in the urine do not differ from those wmich 
usually attend febrile excitement. The urine gradually 
diminishes in quantity and deepens in color until convales- 
cence commences, when it increases in quantity until con- 
valescence is reached. It is rarely albuminous. 

Diarrhoea may occur at any period. It is not usually 
excessive until the second or third week. There is nothing 
characteristic about the discharges. They are usually of 
an exceedingly fetid odor, watery, and dark-colored ; in the 
later stages of the disease they sometimes contain blood. 
In some instances the character of the stools is termed bil- 
ious, and an excessive hepatic secretion is then indicated ; 
at other times they are of a dark clay color, showing a de- 



192 TYPHO-MALARIAL FEVER. 

ficiency of the biliary secretion. With the diarrhoea there 
is usually more or less abdominal tenderness, especially in 
the right iliac region ; but the tympanitis, which is so con- 
stant an attendant of typhoid fever, is rarely well marked 
in typho-malarial fever. In many cases there is retraction 
of the abdomen. 

As I have already stated, headache is a very constant 
and prominent symptom in the early period of this fever. 
It often precedes the ushering-in chill. As the fever pro- 
gresses it gives place to a delirium, which is never violent, 
but which is muttering in character, and is attended by rest- 
lessness and insomnia, or by drowsiness, subsultus, picking 
at the bed-clothes, and great nervous prostration. If deli- 
rium is not present, or after it has disappeared during con- 
valescence, there is great lack of mental vigor and a ten- 
dency to mental sluggishness. The other nervous phenom- 
ena, which are usually present in any condition when 
marked typhoid symptoms exist, are not prominent in this 
fever. The subsequent phenomena which may attend its 
development will vary with the intensity of the fever and 
the resisting power of the patient. 

In fatal cases, towards the close of the second week, 
symptoms of extreme prostration come on, the patient 
gradually passes into a state of stupor, which lapses into 
one of coma, and death ensues. 

In cases that are to recover, by the end of the second 
week the tongue begins to clean, the gastric and intestinal 
symptoms, with the exception of the diarrhoea, begin to 
subside, the pulse becomes slower, the nervous disturbances 
disappear, the appetite returns, and the patient enters on a 
convalescence which is usually protracted. 

It is apparent that the early stage of this fever very 
closely resembles that of simple remittent, while its latter 
stage as closely resembles that of typhoid. 

The phenomena of both stages may be modified by cer- 
tain anti-hygienic surroundings, to which those suffering 
with this fever may have been subjected prior to, and 
during, its development. Thus, when it prevails among 
those who have suffered privations, been badly fed, badly 



SYMPTOMS. 193 

clothed, overcrowded in badly ventilated apartments, sur- 
rounded by decomposing animal and vegetable substances, 
although the fever is attended by the same general phenom- 
ena which characterize the typhoid type, there are certain 
variations which ally it to relapsing fever. Prominent 
among these are neuralgia and arthritic pains in various 
parts of the body, especially in the back and limbs ; hemor- 
rhagic tendencies, marked by bleedings from the gums, 
mucous surfaces ; and not unfrequently large ecchymoses 
occur, in various parts of the body. In this class of cases 
from the commencement the fever is of low type, with quo- 
tidian excerbations and remissions. Diarrhoea usually pre- 
cedes the development of the febrile symptoms. Frequently 
during the second week a muttering delirium comes on, ac- 
companied by drowsiness and a tendency to stupor. De- 
spondency, indisposition to make any exertion, and a state 
of utter indifference as to the future, is frequently met with 
during the entire period of the fever. 

In fatal cases death may be the result of hemorrhage 
from the mucous surfaces, or from exhaustion. In this 
class of cases there is great irritability of the heart and a 
peculiar mental and physical prostration. 

In cases that recover, convalescence comes on late, and is 
slow and tedious. Diarrhoea frequently follows the subsi- 
dence of the fever, which in many cases cannot be eon- 
trolled, and leads to a fatal result. 

The complications which may modify the course of any 
variety of typho-malarial fever are very similar to those 
which are met with in typical typhoid fever. Of these the 
most frequent is inflammation of the respiratory organs, the 
development of which is marked by those symptoms which 
usually attend the development of the different acute pul- 
monary affections. In the majority of instances the signs 
of bronchitis are not present until the fever is well estab- 
lished. The bronchitis resists treatment, and does not dis- 
appear until convalescence is fully established. When 
pneumonia occurs it is catarrhal in character, and few of 
the strongly marked rational symptoms of ordinary pneu- 
monia are present. The physical signs, however, will 
13 



194 TYPHO-MALARIAL FEVER. 

always enable you to determine the presence of pulmonary 
complications, and any great irregularity in temperature 
during the course of the fever should lead you to make a 
careful physical examination of the chest. 

It is sometimes difficult to distinguish between the cere- 
bral symptoms of this fever and those symptoms which 
attend meningeal complications, but the meningeal compli- 
cations are of so very rare occurrence that it is safe to 
assume they are not present until some of the diagnostic 
symptoms of meningitis occur. 

We rarely have serious abdominal complications, such 
as intestinal perforation, peritonitis, and hemorrhage, but 
when they do occur their advent is marked by such urgent 
symptoms that one loses sight of the ordinary symptoms 
of the fever. 

It is hardly necessary for me to refer to those modifica- 
tions in the clinical history of this fever which follow the 
development of abscesses, bed-sores, gangrene, etc. 

Differential Diagnosis. — The aifections with which 
typho-malarial fever are likely to be confounded are ty- 
phoid, remittent, relapsing, typhus, and yellow fever. 

The septic type of typho-malarial fever, in many of its 
phenomena, so closely resembles typhoid fever that frequent- 
ly it is difficult to make a differential diagnosis. I will 
briefly state the points of difference in their clinical history. 

The advent of typho-malarial fever is usually marked by 
a distinct chill, while typhoid comes on insidiously, and is 
not attended by a distinct chill, but by a chilly sensation. 
The rise of temperature in typho-malarial fever is sudden 
and follows no typical range, while in typhoid the typical 
range of temperature during the first week is almost diag- 
nostic of the fever. 

In typhoid fever, on the sixth or eighth day, rose-colored 
spots appear ; these are a distinctive mark between it and 
typho-malarial fever. Although in the latter an eruption 
may be present, yet it has none of the characteristics of the 
typhoid eruption, is not rose-colored, does not disappear on 
pressure, and remains visible throughout the whole course 
of the fever. 



DIFFEEENTIAL DIAGNOSIS. 195 

Besides the absence of these characteristic symptoms of 
typhoid fever, in typho-malarial fever we have a distinct 
periodicity in the febrile action, a certain icteroid hue of 
the skin, hepatic tenderness, extensive splenic enlargement, 
and great gastric disturbance ; conjoined with these the 
appearance of the tongue, the character of the diarrhoea, 
and the non-infectious character of the stools in typho- 
malarial fever serve as important aids in the differential 
diagnosis of these two forms of fever. In typho-malarial 
fever, upon microscopical examination of the blood, we find 
free pigment ; this is never or rarely found in the blood in 
typhoid fever. 

The malarial type of typho-malarial fever resembles re- 
mittent fever in its ushering-in symptoms. In both cases 
there is a chill followed by fever, attended by one or more 
distinct exacerbations and remissions. The early appear- 
ance of the enteric symptoms, attended by other well- 
marked typhoid phenomena by the end of the second week, 
establishes the diagnosis of this type of malarial fever, and 
as the fever progresses the typhoid condition becomes more 
and more apparent. Besides, remittent fever yields more 
promptly to the use of quinine than does typho-malarial 
fever. 

Severe cases of typho-malarial fever, which are compli- 
cated by scorbutic tendencies, marked by petechias and 
great prostration of the vital powers, may be confounded 
with typhus fever ; yet the severity of the attack, the 
higher range of temperature, the greater frequencj^ of the 
pulse, the dusky countenance, the absence of diarrhoea and 
all other abdominal symptoms in typhus fever, renders it 
easy to make the differential diagnosis between the two 
types of fever. Besides, typhus fever has a characteristic 
eruption, is only propagated by contagion, and if it pre- 
vails, does so epidemically. Occasionally yellow fever has 
been confounded with typho-malarial fever, and on this 
account I will mention some of the prominent diagnostic 
symptoms of yellow fever which distinguish it from typho- 
malarial fever. 

The range of temperature is lower in yellow than in 



196 TYPHO-MALARIAL FEVER. 

typho -malarial fever, and on the third or fourth day it falls 
suddenly, and there is more or less complete remission. 
The circumorbital pain, the appearance of the eye, the 
peculiar color of the skin, the character of the matter 
vomited, the absence of diarrhoea, the presence of albumen 
in the urine, and the shorter duration of the disease, will 
enable you to make the diagnosis of yellow fever. Again, 
yellow fever usually prevails epidemically, and is confined 
to certain localities and certain seasons of the year. It is a 
portable disease, and the yellow fever poison may be con- 
veyed from an infected to a non-infected district by means 
of clothing or merchandise, while the poison of the typho- 
malarial fever is of endemic origin, and cannot be carried 
beyond the infected district. 

The points of differential diagnosis between typho-mala- 
rial and relapsing fever will be considered under the head 
of relapsing fever. 

The differential diagnosis between cerebro -spinal menin- 
gitis and typho -malarial fever is sometimes attended with 
great difficulty. 

Prognosis. — The ratio of mortality in typho-malarial 
fever varies greatly in the different regions in which it 
occurs, and as the malarial or septic element predominates. 
The hygienic surroundings of the patient and the range 
of atmospheric temperature will also very greatly influ- 
ence your prognosis. Statistics of this fever in different 
localities and in different years give the ratio of mortality 
from one in twelve to one in twenty-four. The septic type 
is more fatal than the malarial type. Great caution should 
be exercised in prognosticating the result of any case, for 
the apparently mildest cases sometimes suddenly assume 
a severe type and terminate fatally, while very severe 
and apparently hopeless cases unexpectedly improve, and 
recovery takes place. 

The average duration of those cases which terminate in 
recovery is from three to four weeks ; the duration varies 
with the different types of the fever. In the malarial 
variety the duration is always shorter than in the septic. 
The period of convalescence is prolonged ; three or four 



PKOOTOSIS. 197 

weeks often elapse before the patient is completely restored 
to health. A fatal relapse may occur at any period during 
convalescence. In those cases that terminate fatally, death 
most frequently occurs during the second or third week ; it 
may occur as late as the close of the sixth week. 

The occurrence of any of the complications to which I 
have referred as possibly taking place during the course of 
this fever will very materially influence the prognosis in any 
given case. Capillary bronchitis and pneumonia are es- 
pecially dangerous when they develop during the third 
week of the fever. 

Anti-hygienic surroundings, such as overcrowding and 
improper food, materially affect the prognosis. If typho- 
malarial fever prevails among those who are crowded into 
badly-ventilated apartments, who from filth and improper 
nutrition have septic and scorbutic tendencies, the ratio of 
mortality is much greater than among those who are free 
from such complicating influences. 

The symptoms which may be regarded as indicating an 
unfavorable termination are : a continued high temperature, 
showing little or no tendency to remission ; a very frequent, 
feeble, fluttering pulse ; profuse diarrhoea, the discharges 
at times being involuntary and containing mucus, pus, and 
blood ; a dry, red, cracked and fissured tongue ; great 
drowsiness, with a tendency to stupor and coma, and the 
appearance of petechial spots on the surface of the body, 
attended by frequent hemorrhages from the lips, gums, and 
tongue. In a severe case, the occurrence of any of these 
complications renders the prognosis more unfavorable. 
The character of the prevailing fever will also greatly influ- 
ence the prognosis in any given case. If the type of the 
prevailing fever is mild, or if comparatively few deaths 
have occurred, though the symptoms in a given case may 
appear unfavorable, yet recovery is probable. If, on the 
other hand, the type is severe, and many deaths have oc- 
curred, apparently mild cases will suddenly become severe, 
and the prognosis becomes unfavorable. 

As I have already stated, the hygienic surroundings and 
the previous habits of the patient very greatly influence the 



198 TYPHO-MALAKIAL FEVER. 

prognosis. With drunkards, and those enervated by vicious 
habits, a mild type of this fever will probably prove fatal. 

Treatment. — The treatment of typho-malarial fever va- 
ries with its type. JSTo plan can be presented which will be 
applicable to all cases. 

As in other forms of disease, the first question that meets 
us under the head of treatment is, cannot the development 
of this fever be prevented % While speaking of its etiology, 
I stated that its development was principally due to three 
causes — namely, malarial poison, overcrowding, and im- 
proper diet. In a large proportion of instances it is possible 
to do away with the last two causes. The overcrowding 
and the faulty diet may be prevented, and thus the septic 
poison which gives to this fever its typhoid type may be 
destroyed or its development prevented. The strict ob- 
servance of hygienic laws in the localities where this fever 
prevails has in some instances entirely changed the type of 
the disease. Even after the fever symptoms have been well 
developed, the removal of patients from anti-hygienic sur- 
roundings has frequently been attended by the most satis- 
factory results. When isolated cases of this fever are met 
with in localities apparently free from such sources of infec- 
tion, a careful search should be instituted, in order to find 
the source of the infection. Defective sewerage and faulty 
drainage have been found to be fruitful sources of infection. 

The therapeutic measures which may be employed in the 
treatment of this form of fever vary with the type of fever 
and the peculiarities of each individual case. There are no 
specifics. 

In those cases in which the malarial element predomi- 
nates, the administration of quinine as an antiperiodic will 
produce the desired result, and in many instances arrest the 
progress or shorten the duration of the fever ; but in those 
cases in which the septic element predominates, while qui- 
nine may act as an antipyretic in the same way as it does 
in typhoid fever, it has little power to arrest the progress 
or shorten the duration of the fever, but it will, in most in- 
stances, render the course of the fever milder. 

In those cases in which the malarial element predomi- 



TEEATMENT. 199 

nates, which are ushered in by distinct chills, followed by 
one or two distinct remissions and exacerbations, during the 
first remission twenty or thirty grains of quinine, in two or 
three doses of ten grains each, should be administered every 
hour nntil the desired quantity has been given. If it is 
promptly and freely administered, it seldom fails to produce 
a beneficial effect ; nsnally the febrile exacerbations will 
not return, or if they do they are less severe, and in a few 
days entirely disappear. 

In those cases which begin more insidiously and are de- 
veloped more gradually, if there is a distinct periodicity to 
the febrile phenomena, without distinct remission, although, 
by the administration of quinine, you may not shorten the 
duration of the disease, yet the fever will run a modified 
and very much milder course. 

If the first full doses of quinine fail to produce any effect 
in this class of cases, its administration in moderate doses, 
perhaps ten grains twice a day, must be continued for seve- 
ral days before it will markedly modify the severity of the 
fever. In no type of the fever does the quinine exert any 
specific influence except over the malarial element ; the en- 
teric phenomena are either not at all, or only indirectly, 
modified by the antipyretic power of the drug. Hence, it is 
apparent that in those cases in which the malarial element 
is slight, and in which the septic element is prominent, 
while quinine fails to exercise any controlling influence over 
the progress of the fever, it will mitigate its severity, and 
act more powerfully as an antipyretic than it will in any 
other form of continued fever. 

It has been claimed by some that arsenic has a specific 
influence over typho-malarial fever, and that it exercises 
a peculiar and most beneficial effect upon the intestinal 
lesions, materially shortening the duration of the fever. 
There is little doubt but that arsenic, like quinine, acts be- 
neficially in many cases of the malarial type of this fever ; 
but unquestionably this beneficial effect is due to its ac- 
knowledged power over malarial affections, and not to any 
specific influence which it has over the fever. As an anti- 
periodic it is inferior to quinine. 



200 TYPHO-MALARIAL FEVEE. 

The antipyretic treatment of typho-malarial fever does 
not materially differ from that recommended for the reduc- 
tion of temperature in typhoid fever. It is of importance 
to remember that this class of patients do not bear well the 
prolonged application of cold to the surface, either by 
means of the cold bath or the cold pack, and that, unless 
the antipyretic power of quinine is added to the application 
of cold, very little benefit will be obtained from its employ- 
ment. The danger resulting from the injudicious use of 
cold baths is greater in this than in any other infectious 
disease. 

The rules for the administration of stimulants in typho- 
malarial fever are the same as those given for their adminis- 
tration in typhoid fever. The effects of the first few doses 
should be carefully watched. They should never be given 
indiscriminately, for there is greater danger of over-stimu- 
lating in this than in any other fever. Their use is indi- 
cated whenever signs of heart-failure are present, such as a 
feeble pulse and an indistinct first sound of the heart. No 
fixed rule can be laid down as regards the quantity to be 
administered in any given case ; it will vary with the type 
of the fever and the previous habits of the patient ; it should 
always be administered at stated intervals. The period 
of the fever at which stimulants should be commenced will 
also vary. In some cases, stimulants are never required, 
while in other cases, from the very outset of the fever, 
they are demanded. In the majority of cases their use 
is not indicated before the end of the second week. It 
must be borne in mind that alcohol is not a specific, cura- 
tive agent in this fever, but that the object of its adminis- 
tration is to sustain the heart and prevent the vital powers 
from falling below the point at which reparative processes 
are possible. The use of stimulants is not necessarily con- 
tra-indicated when delirium is present. Frequently after 
their administration the delirium will pass away, and only 
when it is decidedly increased by their use should they be 
abandoned. 

The state of the bowels, skin, and kidneys demands the 
closest attention. If, early in the disease, the bowels are 



TKEATMENT. 201 

constipated, a calomel purge combined with ten or fifteen 
grains of quinine will often be followed by marked benefit. 
In any stage of the disease brisk purgation should be 
avoided. If diarrhoea is present, it should not be inter- 
fered with unless it becomes exhausting ; then it should 
be checked by small doses of opium combined with 
astringents. 

When the skin becomes dry and parched, if cold baths or 
packs are not admissible, the surface should frequently be 
sponged with tepid water. It has been proposed by some 
to apply oil to the surface two or three times every day, 
when, from extreme exhaustion or any other cause, bath- 
ing or sponging of the surface cannot be practised. 

Special notice should be taken of the quantity and 
character of the urine. If it becomes scanty and high- 
colored, or if there is a temporary suppression, it is of 
the utmost importance that the functions of the kidneys 
should be immediately restored. This can be best accom- 
plished by the administration of digitalis combined with 
spirits of nitre. Sometimes retention may be mistaken for 
suppression of urine, unless a careful examination be made 
as to the condition of the bladder. Symptoms referable to 
disturbance of the nervous system sometimes require special 
treatment. If there is extreme restlessness, muscular twitch- 
ings, or active delirium, opium may be administered in full 
doses. The effect of the first dose must be carefully 
watched. If sleep soon follows its administration, and the 
delirium gradually subsides without any aggravation of the 
other symptoms, its use may be continued ; if, instead of 
producing sleep, the patient becomes more wakeful, and 
the delirium is increased and more active, and the other 
symptoms are greatly aggravated, its use must be imme- 
diately abandoned. Under these circumstances chloral 
may be tried with great care. 

Some claim that spirits of turpentine in the treatment of 
this form of fever has almost a specific power, while others 
regard it useful only as a stimulant. My own experience 
leads me to employ it only as a stimulant during the second 
and third week of the disease, when there is great prostra- 



202 TYPHO-MALARIAL FEVER. 

tion and marked typhoid symptoms. It may be given as 
an emulsion in doses of twenty drops every two hours. 

The diet best suited to patients with this fever is milk 
administered in the same way as was proposed in the case 
of typhoid fever patients. 

Special complications occurring during typho-malarial 
fever must be met with such remedies as the condition 
of the patient and the peculiar complications may require. 



CONTAGIOUS FEVERS. 



LECTURE XVIII 



TYPHUS FEVER. 

Introduction. — Morbid Anatomy. — Etiology. 

At my last lecture I completed the history of malarial 
fevers. 

I will now commence the history of the contagious fevers ; 
and the first which will engage our attention in this class 
is typhus fever. This fever, like those which we have 
just been considering, depends upon changes produced in 
the blood by a morbific agent developed exterior to the 
body. 

Although it has many phenomena in common with the 
miasmatic contagious fevers, and has until quite recently 
been classed with typhoid fever, yet with our present knowl- 
edge it must be regarded as a distinct type of fever, de- 
pendent upon a specific poison, with certain pathological 
and etiological phenomena which distinguish it from all 
other forms of disease. 

Typhus fever is an epidemic disease. It has received a 
great variety of names, such as " sMp fever ," "hospital 
fever, ' ' ' ' jail-fever, " " camp fever, " " petechial fever, ' ' 
' ' putrid fever, " " continued fever, ' ' and typhus fever. The 
Germans describe an abdominal and cerebral typhus. Their 
abdominal typhus corresponds to our typhoid fever, and 
their cerebral typhus is our typhus fever. 

Morbid Anatomy. — I shall first consider those patholo- 
gical lesions which are common to typhus and typhoid 
fever, and as I draw the line of distinction between them, 



206 TYPHUS FEVER. 

you will notice that in many respects the difference is one 
of degree rather than of kind. 

First, I will speak of the changes in the blood. 

Blood. — The blood in typhus fever is darker in color than 
normal, and when drawn from the body during life coagu- 
lates imperfectly or not at all ; if a clot is formed, it is of 
the consistency of putty. The fibrin is diminished, or to a 
greater or less extent loses its coagulating power. At first 
the red globules are increased in number, but as the disease 
progresses they diminish in number, the salts of the blood 
are also changed, and urea and ammonia are present in 
excess ; by some the latter is supposed to be produced by 
the decomposition of the former. The blood of a typhus 
fever patient, when drawn from the body, rapidly undergoes 
ammoniacal decomposition. When the blood is examined 
microscopically, many of the red blood-globules will be 
seen to have lost their normal outline, and their edges to 
have become serrated and irregular. In some instances 
they will be found to have undergone degeneration ; their 
coloring matter will then pass through the walls of the 
blood-vessels and stain more or less deeply the tissues and 
effusions which may have taken place in the serous cavities. 
These blood- changes are very similar to those which take 
place in the miasmatic contagious fevers — they differ rather 
in degree than in kind. 

Parenchymatous Degenerations. — There is the same 
tendency to parenchymatous degenerations of the different 
organs and tissues of the body in typhus as in typhoid. 
Usually the body is not very much emaciated ; it under- 
goes decomposition much more rapidly after death from 
typhus than after death from typhoid fever. In severe 
cases decomposition apparently commences before death. 
The muscles are usually of a brownish color, dry, present- 
ing an infiltration of fine granules in the primitive fibres ; 
sometimes hemorrhages take place into them. 

The liver and spleen undergo degenerative changes simi- 
lar to those described as occurring in typhoid, but they are 
not so extensive nor are they so constant. You may make 
very many autopsies on persons dying of typhus fever, 



MORBID ANATOMY. 207 

without finding any softening or only a very moderate soft 
ening of the spleen. The parenchymatous changes in the 
kidneys are much more extensive and constant in typhus 
than in typhoid. In severe cases the cortical portion of the 
organs is swollen, opaque, and more or less fatty, according 
to the duration and severity of the disease. The primary 
enlargement of the kidneys is mainly due to a cloudy swell- 
ing of the epithelium of the renal tubes. 

This tendency to cloudy swelling and granular fatty de- 
generation, which* occurs in the voluntary muscles and the 
kidneys, also occurs in the muscular tissues of the heart. 
If the fever is protracted, the cardiac walls become flaccid, 
of a brownish color, and parenchymatous changes are found 
similar to those which occur in typhoid fever, though less 
marked. There is often a considerable amount of serum in 
the pericardium. Pultaceous clots are found in the heart 
cavities, and thrombi are found firmly adherent to the walls 
of the larger veins. 

There is the same tendency to ulceration of the mucous 
membrane of the mouth and larynx as in typhoid fever. In 
typhus fever the ulcers are deeper, involving more exten- 
sively the submucous tissue. 

Splenization of the lungs also occurs in typhus as in ty- 
phoid fever. 

Thus far we have only noticed those lesions which occur 
both in typhus and in typhoid fever. We now come to 
those which are found only in typhus. 

Brain. — Although there is nothing in the appearance of 
the brain which is characteristic of this fever, yet it is very 
unlike that met with in typhoid fever. In the latter dis- 
ease it usually presents an anaemic appearance. In all cases 
of typhus the cerebral vessels will be found more or less 
congested. 

In some epidemics you will find all the sinuses and blood- 
vessels of the brain engorged with dark blood, so that when 
the calvaria is removed the vessels will stand out upon the 
surface of the brain. In other epidemics, instead of finding 
intense congestion, there will be a more or less extensive 
serous effusion into the meshes of the pia mater ; the quan- 



208 TYPHUS FEVER. 

tity of the effusion varies from one to eight or ten ounces, 
and it is most abundant upon the convex surface of the 
brain, although it also takes place to a limited extent into 
the ventricles. Wherever there is a large amount of fluid 
effusion there will be little cerebral congestion. The fluid 
effusion is usually clear ; it may be turbid, and when it is so 
you may be certain that the fever is complicated by menin- 
gitis. The arachnoid loses its natural, glistening appear- 
ance, and in many instances you will find the membrane 
dotted over with yellow or yellowish- white spots. 

The brain undergoes little or no change unless the fluid 
effusion is abundant, when by its pressure the sulci are 
deepened and the convolutions are sharpened. 

It will be seen that instead of having little or no serous 
effusion in the cranial cavity, as is the case in typhoid 
fever, there is either an intense congestion of the cerebral 
vessels, or an abundant fluid effusion underneath the arach- 
noid and into the cavities of the ventricles. In this regard 
there is a marked difference in the appearance of the brain 
in these two forms of fever. 

Abdominal Lesions. — In typhus and typhoid fever, the 
lesions found in the abdominal cavity widely differ. The 
real pathological distinction is in the presence or absence of 
intestinal changes. These are present in typhoid and absent 
in typhus. 

In typhus fever there are no changes which show a ten- 
dency to ulceration of the intestinal glands, except those 
which are produced by congestion, such as is frequently seen 
in scarlet fever and measles, that is, the Peyerian patches 
present the shaven -beard appearance ; while in typhoid 
fever, either ulceration of the intestinal glands will be pres- 
ent, or the glands will present the appearance which just 
precedes ulceration. At the post-mortem examination, if 
ulceration of the agminated and solitary glands is found, 
we may be certain the patient died of typhoid fever. In 
typhus fever there is no enlargement of the mesenteric 
glands, which in typhoid fever is usually present. 

The presence or absence of intestinal changes settles the 
question, is the fever typhus or typhoid % 



MORBID ANATOMY. 209 

Complications. — Although, the complications which occur 
in the course of typhus fever are in no way peculiar to it, 
yet they are of such frequent occurrence, and are devel- 
oped during its active progress and modify its pheno- 
mena to such a degree, that it is necessary that they should 
be taken into account in the study of its pathological 
lesions. You will rarely make a post-mortem upon one 
who has died from this disease without finding the evidence 
of some complication that has occurred during the progress 
of the fever. These complications will vary according to 
the peculiar type of the epidemic which is prevailing at the 
time the death occurred. In one epidemic the complica- 
tions will be pulmonary, in another they will be almost ex- 
clusively cerebral and spinal, in another nearly all will be 
glandular in character. 

The pulmonary complications are bronchitis, pneumonia, 
pleurisy, pulmonary congestion, and oedema. In most 
cases these pulmonary complications are developed during 
the primary fever, before convalescence commences. 

Their advent is always insidious. You may have an ex- 
tensive capillary bronchitis develop with very few of the 
rational symptoms of bronchitis present until within a very 
short time previous to the death of the patient ; in fact, the 
bronchitis might pass unrecognized but for the presence of 
its physical signs. 

All the rational symptoms of pneumonia may also be 
absent, and still a physical examination of the chest may 
reveal a whole lung in a state of pneumonic consolidation. 
The pneumonia which complicates typhus is of the catarrhal 
variety. It often leads to pulmonary gangrene, so that 
gangrene of the lung in connection with the development of 
typhus is not of infrequent occurrence. 

Pleurisy is of so rare occurrence that it may be passed 
with the simple statement that it is an occasional complica- 
tion, its physical signs only revealing its presence. 

At most of the autopsies you make of typhus fever 

patients you will find there has been pulmonary congestion 

and oedema. In many cases, when it is associated with 

capillary bronchitis or pneumonia, it is the immediate cause 

14 



210 TYPHUS FEVEH. 

of death, and great care should be taken in your physical 
examinations that you may detect its commencing develop- 
ment. 

Laryngitis is often associated with the more extensive 
bronchitis which occurs during the active part of the fever. 
The only cerebro-spinal complication which is met with in 
typhus fever is meningeal inflammation. 

As I have stated, in a large majority of autopsies of ty- 
phus fever you will find serum in the meshes of the pia 
mater, but that is not a certain sign that meningeal inflam- 
mation has existed prior to death. In addition to the sub- 
arachnoid effusion, there must be an exudation of plastic 
material ; the arachnoid must have lost its shining appear- 
ance, and be thicker than normal. When such appearances 
are found it shows that the case has been complicated by 
meningitis. The development of delirium and active cere- 
bral symptoms is not positive evidence that the patient is 
suffering from meningeal complication, for the delirium and 
cerebral excitement may occur independently of meningitis. 
It is by the character of the delirium, and by the change 
in the pulse and the appearance of the pupils, that this 
complication is recognized. 

Glandular Enlargements. — The glandular enlargements 
and inflammations which occur in the course of typhus 
fever are peculiar in their character, and are rarely met 
with in typhoid, and then are not extensive ; but in typhus 
fever the external glands of the body — especially those 
about the neck, the parotid and sublingual — often become so 
much enlarged and inflamed as to interfere with deglutition, 
and not infrequently these glandular enlargements are ap- 
parently the immediate cause of death. 

The inguinal glands sometimes become so enlarged as 
to interfere with the return circulation, and, as the con- 
sequence of this interference, swelling of the lower extremi- 
ties may be developed. There is a swelling of the lower 
extremities which depends upon a different cause. It may 
occur at the beginning of convalescence ; then the limbs 
will present very nearly the same appearance as that notice- 
able in the condition called phlegmasia dolens. Under such 



ETIOLOGY. 211 

circumstances you may think the patient lias phlebitis. 
You will recollect that I have stated to you that the volun- 
tary muscles undergo degeneration, and that the same kind 
of degeneration occurs in the muscular tissue of the heart. 
When this does occur the walls of the heart become very 
flabby, and when this change has reached a certain point 
there is developed a tendency to the formation of clots in 
the heart cavities, and a slowing of the general circulation. 
The result of such retarding or obstruction of the return 
circulation is the formation of thrombi in the superficial 
veins, which interfere with the return circulation, and a 
swelling of the lower extremities follows ; this closely re- 
sembles that which is seen in phlegmasia dolens. With 
this swelling of the lower extremities, suppuration and cel- 
lular inflammation may occur, which often results in the 
formation of quite extensive abscesses. 

It is an established fact that whenever the return circula 
tion is slowed from any cause in any disease where there is 
great feebleness of heart power, very frequently thrombi 
form in the veins of the lower extremities. This is often 
well illustrated in the latter stages of phthisis, when swell- 
ing of one or both lower extremities occurs as the result of 
the formation of venous thrombi in the superficial veins. 

Diseases of the organs of the special senses, which so 
frequently complicate typhoid, rarely occur in typhus 
fever, and there are no serious or constant complications of 
the digestive organs. 

We have now noticed the more prominent lesions of 
typhus fever, and although there are none which can be 
regarded as characteristic, still they widely differ from 
those of any other form of fever, and more especially from 
those of typhoid. 

Etiology. — I now pass from the study of the pathologi- 
cal lesions of tj^phus fever to its etiology. At the present 
day this fever is regarded as depending upon a specific 
poison, of whose exact nature we are ignorant. All ob- 
servers agree that in the majority, if not in all instances, it 
is the product of co?itar/io?i, and that the contagion only 
emanates from the bodies of those who are affected with 



212 TYPHUS FEVEK. 

the fever. More recent German writers state that the 
typhus poison is a germ which is capable of indefinite re- 
production. This is a matter of theory, and not fact, for 
no one as yet has been able to determine the existence of 
such germs either by microscopical or chemical research. 
Careful clinical observation has established this fact beyond 
a doubt : that there exists a specific typhus poison, which 
can be communicated from the sick to the healthy, which 
some declare is never of spontaneous origin, while others 
maintain that the poison may be generated " de novo" 

Some have strenuously maintained that it can be devel- 
oj3ed by overcrowding and filth ; others, who have seen the 
largest number of typhus fever cases during the past ten 
years, maintain that at least it is very doubtful whether 
typhus fever is ever of spontaneous origin. It is possible 
to develop a fever from overcrowding, imperfect ventilation, 
filth, and a combination of causes belonging to this cate- 
gory, but such an one is a septic fever, and not typhus 
fever. 

Some observers have gone so far as to express the opinion 
that scarlet fever and typhus are closely allied both in their 
etiology and morbid anatomy, and that typhus fever is no 
more likely than scarlet fever to be of spontaneous origin. 
The results of my investigation of the origin of the epidemic 
of typhus fever which prevailed in this city from July, 
1861 to 1864, have led me to the belief that typhus poison 
is of endemic origin — in other words, that there are certain 
endemic centres ; that Ireland, Italy, and Russia are the 
great centres, and that, whenever it occurs in other locali- 
ties, it has been conveyed from these endemic centres to 
those localities. 

In the month of July, 1861, in one day fourteen cases of 
typhus fever were admitted to the fever wards of Bellevue 
Hospital, of which wards I had the charge. Previous to 
this time, for several years (I think for more than ten years), 
there had been no case of typhus fever in the wards of the 
hospital. Immediately I commenced investigations in 
order to ascertain the origin of the fever in these cases. I 
found that the fever had its origin in the upper story of a 



ETIOLOGY. 213 

rear tenement-house in Mulberry Street, in the most filthy 
portion of the city. The first case was that of a little girl, 
who had been brought into the house, ten days before she 
sickened, from a ship which had come from Ireland, and 
which had cases of typhus fever on board. Two weeks 
after her illness commenced, her aunt, the only other occu- 
pant of the apartments (consisting of a room and dark bed- 
room), sickened of fever and died. In gradual succession, 
nearly every family residing in the building took the fever. 

Becoming frightened, some of these families moved into 
other streets, formed the nucleus for the development of 
the disease in the different localities to which they removed, 
and it soon became a widespread epidemic. There were 
two hundred typhus fever patients at one time in the hos- 
pital. 

These families were as well nourished and lived in as well 
ventilated apartments as thousands of their class in other 
parts of the city. The only difference was that typhus 
poison was brought to them in the person of the little girl, 
and, on account of their badly ventilated apartments and 
their utter disregard of all hygienic laws, they furnished a 
fit soil for the reproduction and spread of that typhus 
poison, the constant and unrestrained intercourse between 
the healthy and the sick being the means by which the 
fever was spread. 

I found unmistakable evidence that persons living in 
healthy localities, simply by visiting friends sick with the 
"fever, contracted the disease. 

The histories of those cases which were developed within 
the limits of the hospital showed that a residence in an at- 
mosphere necessarily more or less tainted with typhus 
poison is not sufficient to develop the disease, but that it 
is necessary for the subject of the contagion to have been 
brought in contact with an infected person, or within the 
atmosphere immediately impregnated with his exhalations. 

The fact that no employee in the hospital, who was only 
brought in contact with the clothing of fever patients, con- 
tracted the disease, as well as the absence of any evidence 
that the disease was propagated by such clothing, goes far 



214 TYPHUS FEYEE, 

to prove that typhus fever cannot be propagated by fomites 
alone. The certainty with which e^ery unprotected person 
who was brought in personal contact with fever patients 
contracted the disease, proves the contagious power of the 
poison. 

The distance that typhus poison can be transmitted 
through the atmosphere (from the manner in which the 
disease was contracted by some of the house physicians), 
would seem to be limited. It has been proved by actual 
experiment that the contagious distance of small-pox, in 
the open air, does not exceed two and one-half feet, and it 
would seem that the contagious distance of typhus fever is 
even less than two and one-half feet. 

The question now arises, can this poison be conveyed in 
the clothing % 

During the epidemic to which I have referred, when ty- 
phus fever patients were brought into the hospital, their 
clothing was removed in the reception room, and after- 
wards washed and packed away in a lower room of the 
building. Upon a most thorough investigation made at 
that time, I found that not a single person contracted the 
disease whose duty it was to wash or pack away the 
clothing ; but every one whose duty it was to carry the 
fever patients from the reception room to the hospital 
ward took the fever. Every physician and nurse who 
had the care of typhus fever patients contracted the 
disease ; those who were on the surgical service escaped. 
Every clergyman who came to administer spiritual conso- 
lation to patients in the fever ward fell a victim to the dis- 
ease. I have brought forward these facts to show that 
during this epidemic there was no evidence that the disease 
was either of spontaneous origin, or that it was transmitted 
from the sick to the healthy except by direct personal con- 
tagion. 

Typhus poison is undoubtedly present in the body exha- 
lations and the expired air of typhus fever patients ; but it 
requires a concentration of the poison to render it infec- 
tious. Slight exposure is not sufficient ; it requires a con- 
centrated poison and a prolonged exposure. The more nu- 



ETIOLOGY. 215 

xuerous the typhus fever patients are, the more powerful 
does the contagion become ; yet a single exposure even to 
such an atmosphere is rarely sufficient to develop the dis- 
ease in an individual who is in good health at the time of 
the exposure. 

If any of you are so circumstanced as to be obliged to 
take the medical charge of typhus fever patients, you 
should make your visits as short as possible, and when you 
are about to auscultate the chest of a fever patient, take a 
full inspiration at an open window, and hold your breath 
while you are listening to the respiratory sounds, never 
inhale the air from the bed of the patient as you examine 
the posterior surface of the chest. As a rule, make your 
visits short to a typhus fever patient, avoid inhaling the 
exhalations of the body, never make a visit until after eat- 
ing ; if you observe these simple directions, you will in the 
majority of instances escape contagion. 

The length of the period of incubation varies. For the 
development of the disease, it usually requires about two 
weeks of exposure, such as comes to one who is around 
those sick with the fever. Repeatedly have I noticed this 
fact in my own case. I have never had typhus fever, and 
have never taken special care to avoid infection. My im- 
munity is probably due to some special constitutional idio- 
syncrasy. I have noticed that whenever I enter upon a 
typhus fever service, I do not experience any effects from 
the exposure to typhus poison until about two weeks has 
elapsed, then I begin to surfer from a peculiar form of head- 
ache which continues for about two weeks ; the period 
before the commencement of the headache corresponds to 
the period of incubation, and the period of headache to the 
average duration of the disease. 

At the present day, the established belief is that typhus 
fever attacks an individual but once, and that those who 
have had typhoid fever are to a certain degree protected 
from typhus. Of all the typhus fever patients treated in 
Bellevue Hospital, only three gave histories of having pre- 
viously had the disease. I recall the case of a man, seri- 
ously ill, who was treated in the fever-tents for typhus fever, 



216 TYPHUS FEVER. 

had the characteristic eruption, left the fever- tents well, 
and in three weeks returned with the fever, and was more 
seriously ill than during his first attack of the disease. 

From the facts which I have brought before you, we must 
reach the following conclusions : 

First. — That typhus fever is due to a specific poison. 

Second. — That this poison is communicated from the sick 
to the healthy only by personal contagion — -that is, the 
recipient of the poison must be brought in contact with 
the personal exhalations of the infected person. 

Third. — That where there is free ventilation, personal con- 
tagion is confined to narrow limits. 

Fourth. — That the evidences of the spontaneous origin of 
typhus are not conclusive, although there can be no ques- 
tion but that overcrowding and bad ventilation favor its 
spread and increase its severity. 

Fifth. — Typhus poison passes into the body mainly 
through the respired air. Whether it can be taken into the 
system in the food and drink is still an unsettled question. 



LECTURE XIX. 



TYPHUS FEVER. 

Symptoms. 

I will continue the history of typhus fever by giving 
you an outline of the phenomena which attend its develop- 
ment, and afterwards speak of some of its more prominent 
symptoms. 

Its advent is usually sudden — there are no constant pre- 
monitory symptoms. In some cases, for a few days, there 
may be a feeling of indisposition, perhaps of headache, loss 
of appetite, and vertigo ; but in a large majority of cases it 
is ushered in by a distinct chill. This differs from the chill 
of pneumonia or that of malarial fever, in that it is short, 
sharp, and sudden. It may amount to nothing more than 
a chilly sensation. Following the chill there is a severe 
and steadily increasing headache ; it is frontal, and increases 
in intensity from hour to hour. This is accompanied by a 
more or less severe pain in the back and limbs, especially 
in the thighs. The headache of typhus is more constant 
and persistent than that which attends the development of 
any other fever ; usually, after a few days it diminishes in 
intensity. A sense of extreme prostration very soon follows 
the ushering-in chill. In some cases the patient is com- 
pelled, within twenty-four hours from the commencement 
of his sickness, to take to his bed from muscular weakness. 



218 TYPHUS FEVER. 

This loss of muscular power will sometimes show itself by 
the unsteady, tottering gait of the patient, and is more 
marked in the early stage of typhus fever than it is in any 
other disease. At one time, while I was making my visit 
in the fever ward, my house physician, who was sickening 
from typhus fever, staggered and fell by my side from loss 
of muscular power. He died on the eighth day of the 
disease. 

Within the first twenty-four hours after the chill the tem- 
perature may rise as high as 105° F. or 106° F., although at 
the same time the patient may complain of a chilly feeling, 
and will draw up to the fire or cover himself with blankets. 

It is a peculiarity of this fever that, during the first two 
or three days, the patient experiences a sensation of cold- 
ness, while the thermometer shows the temperature to range 
at 105° F. or higher. During the first week of the disease 
the temperature remains at 104° F. or 105° F. There will 
be morning and evening variations, most marked at noon 
and midnight ; but these variations follow no regular course, 
as in typhoid fever. From the eighth to the fourteenth 
day the temperature is liable to sudden depression. As a 
rule, the temperature falls between the eighth and four- 
teenth day. There is, without doubt, a day of crisis in this 
disease. In typical cases,, before the fourteenth day there 
is a marked decline, and often a sudden fall in temperature. 
By the beginning of the second week the temperature ranges 
at its highest. If there is a sudden rise in temperature dur- 
ing the second week, it is almost certain evidence that some 
complication exists. 

At first the tongue is swollen and covered with a white 
coating. It presents very much such an appearance as is 
seen in many nervous affections. As the disease progresses, 
after a day or two it assumes a yellowish brown color, and 
the coating becomes thicker ; later it becomes dry, dark, 
and fissured. Nausea is sometimes present, rarely vomit- 
ing. The abdomen is free from pain, except over the liver ; 
the bowels are constipated. Some enlargement of the 
spleen can usually be detected quite early. 

The pulse is accelerated from the very beginning of the 



SYMPTOMS. 219 

fever, ranging from 100 in the morning to 110 or 120 in the 
evening ; the acceleration is greater in children than in 
adults. 

At the onset of the fever the pnlse is full, but it soon 
becomes soft and compressible, and finally feeble. It is 
rarely dicrotic. It is only in the severest cases just preced- 
ing death that the pulse becomes irregular and intermitting. 
The face is flushed, the conjunctivae injected, the expres- 
sion of countenance is dull and heavy, and as the fever 
progresses, the cheeks assume a mahogany color. The 
sleep is disturbed, and when the patient is awake his mind 
is confused ; in very severe cases delirium is very early 
present. 

Between the fifth and eighth, usually on the fifth day of 
the disease, an eruption makes its appearance upon the sur- 
face. It appears first upon the sides of the abdomen, and 
gradually extends over the whole anterior portion of the 
body, except the face and hands. It is more marked upon 
the trunk than on the extremities. At first the eruption 
consists of dirty pink-colored spots, varying in size from a 
mere point to three or four lines in diameter. These spots 
are slightly elevated above the surface, and temporarily dis- 
appear on firm pressure. 

After a day or two the eruption becomes darker in color, 
and assumes a purplish hue. It is no longer elevated above 
the surface, does not entirely disappear on firm pressure, 
and the spots have no well-defined margin. This eruption 
is made up of irregular spots, varying from a point to two 
or three lines in diameter, either isolated or grouped to- 
gether in patches, presenting a very irregular outline ; in 
children it often resembles the eruption of measles. When 
the eruption is abundant it imparts to the skin a mottled 
aspect, which has given rise to the term "mulberry rash oi 
typhus." Another distinctive peculiarity is, that each spot 
or patch remains visible from its first appearance until con- 
valescence is established or death occurs, and it is often seen 
upon the bodies of those who have died of typhus fever. 

In some cases of typhus there are only a few spots of the 
eruption, while in other cases they are very abundant, and 



220 TYPHUS FEVER. 

the surface of the body presents the well-marked mottled 
appearance. In a certain proportion of cases, after the 
eruption which I have just described has been visible for a 
few days, there will appear, scattered over the surface, 
small dark spots, due to minute subcutaneous hemorrhagic 
extravasation ; these are called petechias. On this account 
the disease has been called petechial typhus ; but these 
petechias are by no means distinctive of typhus, for they 
are also met with in other diseases. The majority of cases 
of typhus which you meet will have no eruption except the 
" mulberry rash." When the petechial spots are present 
you will hnd a more severe form of the disease, and more 
extensive blood-changes than usual. 

In all severe cases, at the close of the first week the head- 
ache, which has been the most troublesome symptom, dis- 
appears, and delirium comes on. The delirium will vary 
in character and severity in different epidemics, being much 
more violent and active in some than in others. Some- 
times, at the very outset of the disease, the delirium is very 
active, the patient shouts and talks more or less inco- 
herently, and is more or less violent. If not restrained, he 
may throw himself out of the window. This period of 
intense nervous excitement may last two or three days, 
during which the countenance becomes livid, the conjuncti- 
vas injected, the hands tremulous, and suddenly the patient 
may pass into a state of apparent coma. It is not that 
of complete coma, for the patient can be easily aroused ; 
but he lies upon his back, with a tendency to slip down in 
bed, picking at the bed-clothes. It is not a state of uncon- 
sciousness, although one of apparent coma, for the mental 
processes are going on with great activity, and the imagina- 
tion will conjure up a great variety of horrid fancies, and 
the visions which pass before the patient will be distinctly 
remembered after recovery has taken place. This condition 
has been called " coma vigil." During this period the ex- 
perience of years may be crowded into a day or an hour, 
and the patient may feel that he has lived a lifetime while in 
this state. Those who have the greatest mental power and 
possess the highest culture have the most distressing fancies 



SYMPTOMS. 221 

during this somnolent period. If, in this condition, there is 
a tendency towards a fatal issue, the patient will pass into 
a more complete stupor, and the coma will become more 
and more profound ; the respiration becomes less and less 
frequent ; the pulse, which has ranged at about 120 per 
minute, rises to 140 or 150, and finally becomes impercep- 
tible at the wrist ; the tongue, rolled into a round mass, 
becomes brown and dry, so that the patient is unable to 
protrude it from the mouth ; sordes collect upon the teeth ; 
the conjunctivae are red, and the eyes when open present 
a leaden appearance. The patient has no longer power to 
move his bod}^ ; he lies on his back with his head thrown 
back, perhaps is only able to make slight tremulous motions 
with his hands. The urine collects in the bladder, and, if 
not removed with a catheter, dribbles away. The extremi- 
ties become cold, but the body temperature remains at 105° 
F., or it may rise as high as 107° F. or 108° F. In one 
case under my observation it rose to 110° F. just preceding 
death, while the extremities were cold. 

If the case is tending to a favorable termination, about 
the fourteenth day of the fever there is an amelioration of 
all the symptoms. The patient falls into a quiet sleep, from 
which he awakes conscious and convalescing. The pulse 
and temperature fall, the tongue becomes clean and moist, 
the delirium subsides, and there is a desire for food. After 
two or three days the pulse reaches its normal standard and 
strength gradually returns. This is an outline of the prog- 
ress of the disease in a severe case of typhus fever, termi- 
nating either in death or in recovery. In a mild case there 
will be no delirium. The temperature may not rise above 
102° F. ; the tongue is neither brown nor dry. There is no 
great acceleration of the pulse, never beating faster than 120 
per minute, and that only for a very short period. 

During the entire course of a severe or mild case of ty- 
phus fever, there is no gastric or intestinal disturbance, no 
diarrhoea, no distention of the abdomen, no pain in the right 
iliac fossse, no gurgling — in a word, no abdominal symp- 
toms. 

In mild cases the eruption is never very abundant, but it 



222 TYPHUS FEVER. 

ajypears on the fifth day, and remains visible nntil conva- 
lescence is established. 

I will now speak in detail of the more important symp- 
toms ; those, in fact, which determine the character of the 
fever. 

I have already stated that symptoms indicating disturb- 
ance of the nervous system are among the earliest and most 
prominent. 

Of these, headache is one of the most constant. For the 
first week or ten days it is severe and persistent, after which 
time it gradually abates, and disappears towards the close 
of the second week. 

Delirium comes on usually about the eighth day ; some- 
times it is present at the onset of the disease. At whatever 
period it may be developed, it will continue until the termi- 
nation of the disease. At first the delirium shows itself at 
intervals during the night, or lasts all night, to disappear 
during the day. Its character varies from a low, muttering 
form, to a very active and noisy delirium. 

Every possible variation, as it were, is met with during 
an epidemic of typhus fever. Acute delirium is more liable 
to be present with the intelligent and highly cultured, while 
the delirium is usually low and muttering in character in 
the case of the aged or uncultured. 

Stupor or somnolence in some degree is seldom absent. 
It may develop with or without previous delirium. Usu- 
ally, as the case progresses towards a fatal termination, 
stupor comes on ; this becomes more and more profound as 
the disease advances. The patient often lies for hours ap- 
parently unconscious, with his eyes open as though awake, 
but he is absolutely indiff erent to all that is going on around 
him. This is a condition to which the term "coma vigil" 
has been applied. It is almost invariabty followed by a 
fatal termination. Sometimes coma comes on suddenly, 
without any antecedent somnolence ; under such circum- 
stances the urine will be found loaded with albumen. 

The brain symptoms appear much earlier in typhus than 
in typhoid fever. Loss of muscular strength is an early 
and striking symptom in typhus fever. In the majority of 



symptoms. 223 

cases, it is present from the very first day of the fever. In 
many cases, as the fever progresses, the loss of muscular 
power is so great that the patient is unable to turn in bed ; 
the prostration always increases as the disease advances. 
In some cases there is little loss of strength during the first 
week, but the prostration comes on suddenly during the 
second week of the disease. In addition to the general loss 
of muscular power, in certain cases there is paralysis of 
some muscles, such as the sphincter ani and the muscles of 
the bladder, so that the urine and faeces are discharged in- 
voluntarily. If the muscular coat of the bladder becomes 
paralyzed, there is retention of urine. 

Dysphagia, partial or complete aphonia, and inability to 
protrude the tongue, are due to paralysis of the muscles. 

Muscular tremor is an indication of very great muscular 
prostration, and is usually met with in the aged and infirm, 
and in those who have been addicted to the use of intoxi- 
cating drinks. 

Muscular spasms and subsultus tendinum are present to 
a greater or less degree in all severe cases : the tendons of 
the wrist are most frequently affected. One form of these 
spasmodic movements is manifested by the patient's picking 
or fumbling the bed-clothes ; another by obstinate hiccough. 
All these symptoms must be regarded as of very grave 
import. 

General convulsions are of rare occurrence ; but if they 
do occur, they must be regarded as an alarming symptom, 
as they are usually caused by uraemia. They are most 
liable to occur towards the close of the second week of the 
fever. 

Emaciation is never as marked a symptom of typhus as 
of typhoid. It is rarely present to any great degree before 
the third week of the fever. 

Temperature. — During the first week of typhus fever 
there are no such marked typical variations in temperature 
as are met with in typhoid — none that will enable you to 
make a diagnosis. Usually the temperature rises rapidly 
from the very onset of the fever, and in cases of average 
severity attains its maximum on or before the second or 



224 TYPHUS FEVER. 

third day of the disease. At this period the evening tem- 
perature will range between 103° F. and 106° F. 

Before the temperature reaches its maximum, the morn- 
ing and evening variations are slight. After the tem- 
perature has reached its maximum, for several days there 
will be little change ; but at some time, usually between 
the seventh and tenth day, there will be a slight remission 
until the twelfth or fourteenth day, when it rapidly falls, 
in typical cases that terminate in recovery, to its normal 
standard. 

Occasionally an elevation of two or more degrees pre- 
cedes the fall. This sudden fall about the fourteenth day 
is peculiar to typhus. A very high range of temperature 
during the first week is an indication that severe cerebral' 
symptoms will be developed during the second week of the 
fever. If a very sudden rise in temperature occurs during 
the second week, it indicates the occurrence of some com- 
plication. 

A case of t3^phus fever may terminate fatally, in which 
the temperature at no time has exceeded 103° F. In all 
fatal cases, just preceding death there is usually a rise of 
two or three degrees in temperature. During the first week 
of convalescence the temperature often remains below the 
normal standard, especially in the morning. 

Pulse. — The pulse in this fever is usually frequent, soft, 
easily compressed, and often irregular. The heart may par- 
take of the general muscular weakness, so that the first 
sound may become inaudible. 

In the severe cases, during the first week the pulse may 
reach 120 beats per minute, after which time it increases in 
frequency and feebleness with the severity of the general 
symptoms. By the third day it may reach 120 beats per 
minute, usually in the milder case it does not exceed on 
that day 100 beats per minute. If during the first week it 
continues for three consecutive days so frequent as 120 beats 
per minute, it is an almost certain indication of danger. 
The higher the temperature, and the more frequent the 
pulse during the first week, the more severe will be the 
symptoms during the second week. If during the second 



SYMPTOMS. 225 

week it becomes small, feeble, and frequent, perhaps beating 
140 or 150 per minute, you may regard the case as a very 
unfavorable one. 

In this disease, a favorable change is often marked — first, 
by a gradual, and finally by a sudden diminishing in the 
frequency of the pulse. When this is followed by a sud- 
den increase in frequency, you may look for some compli- 
cation. 

During the first week, if the pulse increases in frequency 
the temperature rises, and if the pulse diminishes in fre- 
quency the temperature falls ; but, during the second 
week, the pulse may increase in frequency, and yet the tem- 
perature may fall, and the pulse may diminish in frequency 
and yet the temperature rise. 

The pulse is not an infallible guide as to the condition of 
the heart, for sometimes the pulse is full and distinct while 
the heart power is very much enfeebled ; on the other hand, 
the cardiac impulse may appear strong and the sounds dis- 
tinct, and yet the radial pulse may be imperceptible. In 
most fatal cases, after the first week the radial pulse is im- 
perceptible for several days prior to death. Although in 
most severe cases of typhus fever there is a rapid pulse, 
yet a slow pulse does not necessarily indicate a mild attack. 

Eruption. — The general character of the eruption of 
typhus fever has already been described. 

I will repeat some statements already made to you. The 
eruption appears on the sixth or seventh day of the fever. 
Its appearance is preceded and accompanied by a fresh red- 
ness of the whole surface, on which dark red spots are 
scattered, giving the skin a mottled appearance. These 
spots have an irregular outline, and vary in size from a 
point to three or four lines in diameter. Sometimes they 
are few in number, but more commonly they are numerous ; 
the larger spots are formed by the coalescence of the smaller 
ones. At first they have a dusky pink hue, partially or 
wholly disappearing on pressure, and as the finger passes 
over them they seem to be slightly elevated. After a day 
or two they assume somewhat of a brick-dust color, and are 
but slightly changed by pressure ; then the color of the 
15 



226 TYPHUS FEVER. 

spots becomes still darker and darker in hue, and finally 
they are not affected by firm pressure. Another peculiarity 
is that each patch or cluster remains visible from its first 
appearance until the termination of the disease. The erup- 
tion may appear upon any portion of the body. Usually 
it first makes its appearance upon the trunk, soon spread- 
ing to the extremities ; very rarely is it seen on the face. 
When the eruption is scanty, it is limited to the chest and 
abdomen. In some patients the eruption, though well de- 
veloped, is not prominently marked ; the spots are pale 
and undefined, and though grouped in patches are so 
irregular that they give to the entire surface a faint, dingy 
appearance. The question now arises, is the presence of 
this eruption so constant in typhus fever that by it we may 
with certainty make the diagnosis of this disease % 

I believe that it may be discovered by a careful examina- 
tion in nearly every case of typhus fever ; it is more likely 
to be indistinct in children than in adults. 

When typhus fever is prevailing, an ephemeral fever is 
often met with, which has many of the prominent symptoms, 
but not the characteristic eruption of typhus fever. This 
ephemeral fever or febricula is undoubtedly due to typhus 
poisoning, yet it is not typhus fever. In a case of fever, 
where there is a question as regards diagnosis between ty- 
phus, typhoid, malarial, and septic fever, all of which have 
many phenomena in common, I should not be willing to 
make the diagnosis of typhus fever unless the eruption was 
present. 

Respiration. — Usually, during the first week, the res- 
pirations do not exceed twenty or thirty per minute, but 
during the second week they often run up to forty or fifty 
per minute. In cases where there is great prostration ac- 
companied by stupor, the respirations sometimes fall to 
eight or ten per minute. Under such circumstances they 
are often irregular and purling in character. Hypostatic 
congestion of the lungs, if extensive, is attended by great 
frequency of respiration and evidences of cyanosis. The 
occurrence of these changes in respiration ought always to 
lead you to make a careful examination of the chest. The 



SYMPTOMS. 227 

breath of a typhus fever patient has an odor which closely 
resembles that exhaled by the skin. 

The digestive system, which is so greatly affected in ty- 
phoid fever, is very little, if at all, disturbed in typhus 
fever. Nausea and vomiting are rare, and an examination 
of the abdomen presents nothing abnormal. There is no 
tympanitis or tenderness on pressure. Spontaneous diar- 
rhoea is of exceedingly rare occurrence ; the bowels are 
generally constipated. Intestinal hemorrhage is of rare 
occurrence, and when it is present depends either upon 
congestion of the mucous membrane of the colon or on 
hemorrhoids, which accompany an engorged portal circu- 
lation. 

Urine. — The urine in typhus undergoes important 
changes. The quantity varies somewhat with the amount 
of fluid taken into the stomach ; usually it is diminished 
during the first week, sometimes to one-fourth the normal 
quantity. In the advanced stage of severe cases there is 
sometimes complete suppression of urine, but more fre- 
quently the quantity of urine increases during the later 
stages of the fever. 

The quantity of urea excreted in twenty-four hours dur- 
ing the first few days of the fever is increased, and the in- 
crease is in proportion to the intensity of the fever. In the 
majority of cases it remains abnormally increased until the 
period of crisis is reached (about the fourteenth day), when 
it gradually, or in some instances rapidly, falls below the 
normal standard. 

In all severe cases, during the first week of the disease, 
a small amount of albumen is always found in the urine ; 
when the quantity is large, the case may be regarded as very 
severe. 

In the severer cases the urine will also be found to con- 
tain vesical and renal epithelium, and when the quantity of 
albumen is large, epithelial and fatty casts of the urinifer- 
ous tubes will be present. 

In this connection it is important to bear in mind the ne- 
cessity of daily inquiry into the expulsive power of the 
bladder. When there is little cerebral disturbance, the 



228 TYPHUS FEVER. 

urine is passed without difficulty ; but when stupor and 
a tendency to coma exist, there is often retention or an 
involuntary dribbling of urine, which might lead one to 
think that there was no accumulation of urine in the 
bladder. 

It is safe to inquire, at least once a day, as to the state of 
this organ, and if involuntary discharges of urine occur, 
the contents of the bladder should be evacuated by means 
of a catheter. 



LECTURE XX 



TYPHUS FEVER. 

Symptoms. — Differential Diagnosis. — Prognosis. 

This morning I will speak of the complications of typhus 
fever, and its differential diagnosis. 

In typhus as well as in typhoid fever, you must be pre- 
pared for the occurrence of complications. Although they 
do not properly belong to the primary disease, yet they 
so modify it that they enter very largely into its history. 
Reference has already been made to them under the head 
of anatomical lesions, yet it is necessary that I should 
again speak of them under the head of symptoms. In 
a large number of cases which terminate fatally, death is 
due to some one of these complications. Most of these 
commence before the cessation of the primary fever ; oc- 
casionally convalescence is interrupted by their occur- 
rence, and indefinitely prolonged. Doubtless, in many in- 
stances, they depend upon the weakened condition of the 
heart induced by the typhus poison. In some epidemics 
they are all pulmonary ; in others they are all cerebral. 
The advent of pulmonary complications in this fever is al- 
ways insidious ; the cough and expectoration which usually 
attend pulmonary diseases are either absent, or so slight as 
not to attract the attention of the physician. 

Frequently, rapid breathing and lividity of the face are 
the first obvious indications of extensive disease of the 
lungs. When these symptoms are present, a careful physi- 
cal examination of the chest should be made. 



230 TYPHUS FEVER. 

Bronchitis may come on at any period during the fever, 
and it may continue after the fever has subsided. So long 
as it is confined to the larger tubes there is little danger, 
but sometimes suddenly and insidiously it extends into the 
smaller tubes and is complicated with pulmonary congestion 
and oedema. Under such circumstances it may be the direct 
cause of death. 

The pneumonia which complicates typhus fever is lobular 
in character, and frequently is preceded or accompanied by 
bronchitis. It has a tendency to terminate in abscess or 
gangrene. During life it is not always possible to distin- 
guish it from hypostatic congestion. If, however, the dul- 
ness on percussion is confined to one lung, if the respiration 
is bronchial and the pneumonic sputa is present, the pneu- 
monia is readily established. The seat of the pneumonia is 
generally at the upper portion of the lung. 

Laryngitis is sometimes a very serious complication of 
typhus. It may be croupous in character, but the more 
common form is that of acute cedema glottidis. Its occur- 
rence is readily recognized by the signs of laryngeal obstruc- 
tion which attend its development. Whenever you meet 
with extensive swelling of the glands about the neck, with 
great tumefaction of the mucous membrane of the pharynx, 
you must be on the watch for the occurrence of this compli- 
cation. 

On account of the extensive blood-changes which some- 
times occur in severe cases of typhus fever, the blood readily 
escapes through the walls of the vessels, giving rise to ex- 
tensive hemorrhages from the mucous surfaces and into the 
cellular tissue. The occurrence of the hemorrhages is pecu- 
liar to certain epidemics, and when they occur it is during 
the first week of the fever. 

Meningitis is the only cerebral complication which you 
will probably meet with in this fever. This occurs more 
frequently in children than in adults, and is not present in 
every epidemic. The cerebral symptoms, which are such 
constant attendants upon typhus fever (as I have already 
stated), do not depend upon meningeal inflammation ; they 
belong to the regular history of the disease. If, during the 



SYMPTOMS. 231 

course of the fever, there is a deep-seated pain in the head, 
with restlessness, which shows itself by a constant attempt 
to get out of bed, with photophobia, contracted pupils, and 
Mushing of the face and eyes, followed by somnolence grad- 
ually lapsing into coma, you may be almost certain that 
meningitis is occurring as a complication. This is most lia- 
ble to occur during the second week of the fever. The char- 
acteristic symptom which marks its development is the con- 
stant attempt on the part of the patient to get out of bed. 
He is so persistent in this that unless watched with the 
greatest care he will be found upon the floor, vainly at- 
tempting to rise. The patient has more muscular power 
than before the occurrence of the meningeal complication, 
for he will perform acts which previously he was wholly 
unable to perform. Usually the delirium lasts two days, 
then the patient gradually passes into a state of coma from 
which he cannot be aroused ; his respirations may not be 
more than eight or ten per minute. Dilatation of the pupils, 
and an intermitting and almost imperceptible pulse, imme- 
diately precede death. 

I have already referred to the anatomical changes in the 
kidneys, which are so frequently met with in the course of 
this fever. I prefer to regard most of these changes as a 
part of the history of the fever rather than as a complica- 
tion, although in some few instances croupous nephritis oc- 
curs, which must be included in the list of complications. 
Its occurrence in the course of typhus fever is indicated by 
the almost entire suppression of urine, and by the presence 
of albumen in the urine, and exudative and blood casts. 

Glandular swellings are also occasional complications 
of typhus fever, and sometimes may be of a very serious 
nature, for they may so interfere with deglutition and 
respiration as to destroy the life of the patient. These 
swellings usually appear immediately after the crisis of the 
primary fever. They often enlarge with great rapidity, and 
in some instances terminate in extensive suppuration. 

I have now briefly given you an outline of the symptoms 
which mark the development and progress of a case of ty- 
phus fever, and also of the prominent complications which 



232 TYPHUS FEVER. 

may occur during its progress. There are certain accidental 
or occasional complications which cannot strictly be re- 
garded as a part of the history of this fever, as they may 
occur with any other fever. To these I shall not refer. 

Duration. — The duration of typhus fever is considera- 
bly shorter than that of typhoid fever, and it is of great 
importance, both as regards prognosis and treatment, to be 
able to fix the time of its continuance. Usually the day of 
crisis is between the tenth and sixteenth day. The average 
duration of the fever is thirteen or fourteen days. It is of 
shorter duration with the young than with the old, with 
children than with adults. 

Relapses are extremely rare in this fever. I have met 
with a second and third attack of the fever in the same 
individual, but I have never met with a true relapse. 

Typhus fever varies very slightly in its general character 
in different cases. Authors have described a number of 
different varieties, depending on the mildness or severity of 
the disease, the prominence of certain symptoms, the pres- 
ence of complications and the circumstances under which 
the fever appears ; but the general description of the fever 
which I have already given you includes that of the so- 
called different varieties. 

Differential Diagnosis. — Before the appearance of the 
eruption, the diagnosis of typhus fever is always difficult, 
and sometimes impossible. The diseases with which it is 
most liable to be confounded are typhoid fever, relapsing 
fever, measles, pneumonia, acute BrigliVs disease, menin- 
gitis, delirium tremens, and some of the other acute blood 
diseases, such as erysipelas, pyaemia, septicemia, etc. 

The early characteristic symptoms of typhus fever are 
chilliness, pain in the back and limbs, and headache. 
During the first week the headache increases in severity from 
hour to hour, and is accompanied by a rapid rise in tem- 
perature. These S3anptoms occurring in one who has been 
exposed to typhus poison are almost sufficient for a diag- 
nosis. The appearance of the eruption settles the question. 

On account of the similarity in appearance of the eruption 
of typhus fever and that of measles, in children, the one 



DIFFERENTIAL DIAGNOSIS. 233 

disease is sometimes mistaken for the other. In both dis- 
eases the eruption may appear on the fifth day, but the erup- 
tion of measles is of a brighter tint than that of typhus 
fever, and its appearance is preceded by a cough and co- 
ryza, which are not present in typhus fever. 

Meningitis. — The differential diagnosis between typhus 
fever and cerebro-spinal meningitis is difficult. Not un- 
frequently, days may elapse before you are able to decide 
whether a case is one of typhus fever or of cerebro-spinal 
meningitis. To show how difficult is the diagnosis between 
these two affections, I will mention a circumstance which 
occurred a short time since in Bellevue Hospital. A pa- 
tient was brought into the hospital directly from a ship, 
and the diagnosis of cerebro-spinal meningitis was made by 
several of the attending staff ; but at the autopsy there were 
found none of the lesions of meningitis, but all the changes 
corresponded to those found at the autopsies of patients 
dying of typhus fever. 

Yet there are many distinguishing points of difference 
between the two diseases. The headache of meningitis, at 
the outset of the disease, is more distressing than that of ty- 
phus, and it alternates with delirium. These are the early 
symptoms of meningitis. When delirium comes on in ty- 
phus fever, the pain in the head ceases. 

Photophobia and contracted pupils are among the early 
symptoms of meningitis, and the patient is greatly dis- 
turbed by noise, while in typhus fever he seems indifferent 
to both. Inequality of the pupils, strabismus, ptosis, and 
paralysis are common in meningitis and rare in typhus. 
In meningitis the countenance is expressive of pain, wild- 
ness, and anxiety ; in typhus fever it is blank and stupid. 

Again, in meningitis the pulse is first slow and full, then 
rapid and irregular, and lastly intermitting ; while in 
typhus fever it is rapid at the outset of the disease, and is 
easily compressed. 

Lastly, the eruption of typhus fever is characteristic. If 
an eruption is present in meningitis, it has no regularity 
in its development ; it may appear within twenty-four 
hours after the development of the first symptom of the 



234 TYPHUS FEVEE. 

disease, or it may be postponed for several days, or it may 
not appear at all. It does not appear on the fifth or sixth 
day of the disease, with the uniform regularity of the erup- 
tion of typhus fever. You may find petechise in meningitis 
as well as in typhus fever, but, as I have already told you, 
they are not characteristic of the latter disease. 

The temperature rises more rapidly in typhus fever than 
in meningitis, and reaches a higher range. Rigidity of the 
muscles of the neck is not always positive evidence of 
meningitis, for sometimes it occurs in typhus fever. 

Pneumonia. — Sometimes a latent pneumonia with ty- 
phoid symptoms is mistaken for typhus fever ; especially is 
this the case when the latter is prevailing. I frequently 
saw cases where such a mistake had been made, while in 
charge of the typhus fever patients on Black well's Island, 
during the epidemic to which reference has been made. 
In these cases you will have active typhoid symptoms, 
such as dry tongue, delirium, high temperature, etc. The 
countenance in this pneumonia, although the cheeks may 
have a purplish hue, does not exhibit that dull, heavy 
expression so commonly seen in typhus fever. Although 
there may be delirium in both instances, the delirium in the 
former disease is of a milder type than in the latter. The 
characteristic pneumonic expectoration is not usually pres- 
ent in these cases, and you must not therefore rely upon 
that symptom in making your differential diagnosis. The 
physical signs of pulmonic consolidation will lead you to 
pneumonia, and, unless the typhus eruption is present, 
this will be sufficient for a diagnosis. If pulmonary con- 
solidation is a complication of typhus fever, it will not be 
developed until after the sixth day of the fever, the time 
when the eruption should have appeared. If no eruption 
is present, the pneumonic consolidation may be regarded as 
the primary affection, and the symptoms which simulated 
those of typhus fever may be regarded as secondary. 

Delirium Tremens. — The delirium of "delirium tremens" 
may sometimes so closely resemble that of typhus fever, 
that the one may be mistaken for the other. The mistake 
has been made in Bellevue Hospital, and typhus fever pa- 



DIFFERENTIAL DIAGNOSIS. 235 

tients have been placed in the cells, supposing them to be 
cases of delirium tremens. If the "delirium tremens" is 
uncomplicated by pneumonia, take the temperature of the 
patient ; then it will be very easy to make a differential 
diagnosis, for in "delirium tremens" the temperature is 
rarely above 100° F., while in typhus fever with delirium 
the thermometrical range is 104° F. or 105° F. You may 
have a rapid pulse in delirium tremens, and often the patient 
has a brown, dry tongue, and other typhoid symptoms ; 
but there is only a slight rise in temperature ; besides, 
there is no eruption present. The attack is not ushered in 
by headache, but by an inability to sleep, and the circum- 
stances which precede and give rise to such an attack will 
establish beyond a doubt the true nature of the attack. 

Acute BrigliVs Disease. — It is not surprising that acute 
uraemia from acute parenchymatous nephritis should be 
mistaken for typhus fever. The brown, dry tongue, the 
tendency to stupor, the contracted pupil, the low mutter- 
ing delirium, and all the phenomena of the typhoid state, 
as well as the albuminous urine, belong to both diseases ; 
but the temperature is not raised in uraemia as it is in typhus 
fever, and the oedema which is always present in acute 
uraemia is absent in typhus fever. 

Erysipelas, pyaemia, septicaemia, and all similar acute 
blood diseases are often attended by many of the symptoms 
which attend the development of typhus fever. 

In pyaemia and septicaemia you have irregular chills, 
followed by fever and profuse sweats, with evidences of 
septic and pyaemic poisoning ; in erysipelas, you have the 
evidences of a localized phlegmon. You must remember 
that erysipelas is sometimes ushered in by all the phenomena 
that attend the ushering in of typhus fever ; this is before 
the local inflammation shows itself. In such cases it is im- 
possible to make a differential diagnosis until the local 
phenomena which characterize erysipelas show themselves, 
or until the typhus eruption appears. In many of the acute 
infectious diseases you will be compelled to wait until the 
time for the appearance of the eruption before you can ex- 
clude typhus fever. 



236 TYPHUS FEVEK. - 

When typhus fever is prevailing, and yon are watchful 
in regard to its appearance, you will usually have little 
difficulty in diagnosis. 

You must alway bear in mind that sometimes typhoid, 
typhus, and relapsing fever prevail at the same time, in the 
same locality. 

The importance of early forming a correct differential 
diagnosis between typhus and typhoid fever cannot be over- 
estimated; and in order that you may be the better able to 
accomplish this, I will now review the prominent symptoms 
of each, and compare them. By so doing, we shall review 
their etiology, morbid anatomy, etc. 

The first point to be considered in the differential diag- 
nosis of these two diseases is, that typhus fever is sudden 
in its advent, while typhoid fever comes on insidiously, and 
is slowly developed. In the majority of cases of the former 
disease there is a chill at the commencement, and severe 
pain in the head, whereas in the latter there is only a chilli- 
ness, some aching in the limbs, and a slight headache. 
Muscular prostration and progressive muscular weakness 
appear earlier and are much more marked in typhus than 
in typhoid. 

Second. — The range of temperature in the two forms of 
fever greatly differs. For example, in typhoid fever we 
commence on the first day with a slight rise in temperature, 
which continues, with morning remissions and evening 
exacerbations, until the end of the first week, when it has 
reached its highest point ; during the second week it re- 
mains at about the same degree, with only slight variations ; 
during the third week there are more marked morning re- 
missions ; and by the end of the fourth week the tempera- 
ture has reached its normal standard. 

In typhus fever, the temperature rises rapidly, and before 
the end of the second day reaches 104° F. or 105° F. 
Whatever degree is reached on the third day may be re- 
garded as the maximum temperature ; after this time there 
are slight, irregular variations until the tenth or twelfth 
day, when the temperature begins to fall, and rapidly reaches 
the normal standard. 



DIFFERENTIAL DIAGNOSIS. 237 

Third. — These two forms of fever differ very markedly as 
regards the eruption. 

In typhus fever the eruption makes its appearance upon 
the fifth or sixth day ; while the eruption of typhoid fever 
makes its appearance between the seventh and ninth day of 
the fever. The eruption of typhus appears upon the arms 
and chest, and more or less over the entire body ; whereas 
the eruption of typhoid appears upon the chest and abdo- 
men, very rarely upon the extremities ; sometimes it ap- 
pears upon the loins when it cannot be found on any other 
part of the body. As a rule, the spots in typhus are nu- 
merous ; while in typhoid they are not very abundant. 

In typhus fever, at first the spots are small, slightly ele- 
vated, of a dark pinkish hue, and disappear only on firm 
pressure. As the disease advances they become darker, 
and finally are not affected by firm pressure and remain 
visible from the time of their appearance until death occurs 
or convalescence is established. In typhoid fever each 
spot is rose-colored, slightly elevated, and disappears on 
slight pressure. Each spot remains visible for three days 
and then disappears, to be followed by another crop. Usu- 
ally, the eruption is visible about two weeks, and when it 
disappears leaves the skin unstained, whereas in typhus the 
eruption disappears and leaves a stain upon the surface. 
There is a mottling of the surface in typhus fever which is 
not seen in typhoid, and has been described as the mul- 
berry rash. 

It would seem as though a differential diagnosis might be 
as easily made between the eruption of these two forms of 
fever as between the eruption of measles and that of scarla- 
tina. There may be cases which will cause you to hesitate 
as regards diagnosis, but when the eruption is developed 
there need be no question as to which form of fever it be- 
longs. 

Fourth. — The brain S3 x mptoms in these two diseases also 
differ. In typhus fever they appear early, and the head- 
ache and delirium are more intense than in typhoid. Deli- 
rium in typhoid more commonly appears at the end of the 
second or during the third week of the disease ; whereas in 



238 TYPHUS FEVEK. 

typhus it appears early, and before the end of the second 
week has disappeared if recovery is to take place. 

Fifth. — As a rule, in typhus fever constipation is present, 
and you will be obliged to make use of some mild cathartic 
in order to move the bowels ; whereas in typhoid fever diar- 
rhoea is one of the prominent symptoms. 

Tympanitic distention of the abdomen, gurgling, and ten- 
derness in the right iliac fossse, and perhaps intestinal 
hemorrhage, are all phenomena of typhoid fever, but are 
never present in typhus fever. 

Sixth. — Another point in differential diagnosis relates to 
the duration of the fever, and here we have a marked differ- 
ence. 

In typhus fever, usually convalescence will be established 
before the end of the second week ; some say the tenth is 
the critical day, but I think it may be any day between the 
eighth and fourteenth. The average duration of typhus 
then may be regarded as fourteen days ; whereas in typhoid 
fever the average duration is from twenty-one to thirty 
days ; twenty-one the minimum, and thirty the maximum 
number of days. 

Seventh. — Typhus fever is contagious ; typhoid fever is 
non-contagious. Typhus fever is due to an animal poison ; 
typhoid fever is due to an animal poison developed in con- 
nection with vegetable decomposition. 

The fact that one is contagious and the other non-con- 
tagious renders the differential diagnosis of great importance. 

Eighth. — When we come to the pathological lesions, and 
consider the manner in which death occurs in these two 
forms of fever, we readily see how widely they differ. 

The characteristic pathological lesions of typhoid fever 
are the changes which take place in the intestinal glands, 
such as ulceration or tendency to ulceration. In all cases 
these characteristic lesions are present. 

Suppose you have a case of what you have called typhoid 
fever, and you follow it to the dead-house, but do not find 
ulceration or evidences of a tendency to ulceration of 
Peyer's patches, then you may be quite sure that you have 
made a mistake in diagnosis. 



prognosis. 239 

If, on the other hand, you have a case of supposed 
typhus fever, and you follow it to the dead-house, and find 
ulceration of Peyer's patches, you maybe equally certain 
that you have made a mistake, and that you have been 
treating a case of typhoid, and not typhus fever. 

The parenchymatous changes which are common to both 
diseases have already been sufficiently considered. 

Lastly. — Typhus fever is generally epidemic ; typhoid is 
always endemic. In regard to the protection which one 
attack of typhus fever furnishes against a second attack, it 
very markedly differs from typhoid fever. One may have 
typhoid fever whenever the system has been exposed to the 
typhoid poison ; but one attack of typhus is almost a cer- 
tain protection against a second attack. 

Prognosis. — The prognosis in this disease is always 
grave, and should not be given until you have very care- 
fully considered all the points in each case : such as the 
age of the patient, the character of the epidemic, and the 
tendency to certain complications. In all epidemics, the 
majority of cases will recover. The ratio of mortality as 
given by different writers, varies from one death in five 
cases to one death in sixteen cases. The surroundings of 
each patient should be carefully noted, also the hygienic 
influences which he is under, and his habits of life should 
be taken into account. With the intemperate the disease is 
likely to prove fatal. Some of the circumstances which 
increase the danger in any particular case are, a debilitated 
condition of the patient from advanced age, intemperate 
habits, privation, and previous disease ; mental depression, 
presentiment of death, and over-crowding and bad ventila- 
tion ; a gouty diathesis is always dangerous. Death may 
occur in typhus fever from three general causes : 

First. — From coma. This is the result of overwhelming 
the system with typhus poison. The patient does not die 
from the effect of a prolonged high temperature, nor from 
complication, but dies as patients die in acute uraemia, 
because the system is overwhelmed by the typhus poison, 
and the functions of organic life are arrested by its action 
on the nerve-centres. 



240 TYPHUS FEVER. . 

Second. — Death may occur from syncope due to heart 
failure, whether the heart failure is the result of the pro- 
longed high temperature, or the direct action of the typhus 
poison. A continued temperature of 105° F. or 106° F. is 
very liable to be followed by fatal syncope from failure of 
heart power, although the evidences of parenchymatous 
degeneration of the heart may not be present. 

Third. — Death may occur from complication. 

Let us now study in detail the individual symptoms and 
signs which render the prognosis unfavorable. 

A pulse of more than 120 per minute, continuing a num- 
ber of days, intermittent, and sometimes irregular, bespeaks 
an unfavorable prognosis. 

A hurried and difficult respiration, with turgidity of the 
face, due either to cerebral or pulmonary oedema, renders 
the prognosis unfavorable. 

Delirium which is very active and accompanied by great 
muscular prostration, as indicated by subsultus, slipping 
down in the bed, and accompanied by that condition known 
as " coma vigil," lasting for a number of days, is almost a 
certain indication of a fatal termination. 

The " pin-hole pupil " mentioned by the old writers is an 
unfavorable omen. It does not necessarily indicate the 
presence of meningitis, as was once supposed. Great mus- 
cular prostration at the very onset of the disease renders 
the prognosis unfavorable. 

Marked impairment of the special senses, accompanied by 
very great rapidity of the pulse, is an element of unfavor- 
able prognosis. 

The more abundant and the darker colored the eruption, 
especially if accompanied by petechial spots, the more un- 
favorable the prognosis. In children the eruption is lighter 
in color than it is in adults, presenting an appearance 
similar to the typhoid eruption. In adult cases, where 
there is dark mottling of the surface confined to the ex- 
tremities, with evidences of blood extravasation, indicated 
by the presence of petechise, your prognosis must be un- 
favorable, but the case is by no means hopeless. 

A dry, brown, retracted, tremulous tongue is seen only in 



PEOGNOSIS. 241 

severe cases. A long- continued high temperature is always 
an unfavorable symptom. Great diminution in the quantity 
of urine is an unfavorable symptom, as is also the presence 
of casts and albumen in the urine. Retention of urine is a 
more unfavorable symptom than incontinence of urine ; 
convulsions and coma are liable to follow such retention. 

You must remember that in typhus fever, more than in 
any other disease, the patient may pass into an apparently 
hopeless condition, and afterwards rally and recover. A 
patient who seems to be overwhelmed with the poison, who 
has "coma vigil," "pin-hole pupils," rolling of the tongue, 
and a feeble, irregular, but intermitting pulse, may recover, 
although these symptoms warrant an unfavorable prognosis. 

"Coma vigil," more than any single symptom, warrants 
an unfavorable prognosis. 

The first indication of recovery is a diminution in the fre- 
quency of the pulse. The pulse may have been 120, but on 
the tenth, twelfth, or fourteenth day, it begins to diminish 
in frequency. The tongue has been brown and dry, sub- 
sultus and delirium may have been present, even " coma 
vigil" may have manifested itself ; there has been great 
muscular prostration ; the patient, attempting to rise from 
the bed, may have fallen upon the floor ; now, the pulse 
begins to get slower, the patient falls into a refreshing sleep 
and awakes perfectly conscious ; his countenance is changed 
from the dusky hue to an almost natural appearance, and 
he desires food. In other words, within twenty-four hours 
an entire change comes over the patient, and that change is 
first indicated by a diminution in the frequency of the pulse, 
accompanied by a fall in temperature. The fall in tempera- 
ture is not extreme ; perhaps a fall of two degrees is first 
noticed. 

My experience goes to show that there is an attempt at 
convalescence upon the eighth day of the fever. Especially 
in those cases that recover, upon that day you will notice 
a slight fall in temperature, although the temperature may 
again rise ; upon the twelfth or fourteenth day there is a 
distinct fall in temperature and diminution in the frequency 
of the pulse that is indicative of convalescence. 
16 



242 TYPHUS FEVEK. 

The mode of recovery in these two forms of fever, typhus 
and typhoid, is perhaps the most distinguishing clinical 
feature. In typhus, recovery is rapid ; while in typhoid it 
is markedly slow. 

Of all the conditions which influence the prognosis in ty- 
phus fever, age and the liabits of tlie patient have as great, 
if not greater, influence than any other. I am convinced of 
this from an experience in the care of typhus fever patients 
which dates back almost to the very commencement of my 
study of medicine, for very early did I have the care of a 
typhus fever ward. 

In children, typhus fever is a very simple form of disease. 
The rate of mortality is very low. I remember having the 
care of sixty children with typhus fever, and among these 
only one death occurred. This is as low a rate of mortality 
as you can expect in measles. 

When the patient has passed the middle period of life, 
there is great danger from typhus fever. So with the in- 
temperate, and those who have lived amid unfavorable hy- 
gienic surroundings. 

The bright, educated person, the one with an active brain, 
is less likely to recover than is the stupid, uneducated one. 
For example, the hod- carriers may have the worst type of 
typhus fever, and pass through it with safety, stupid when 
they contract the disease, and stupid when they get well. 
Let a man with an active brain contract the disease, and the 
"coma vigil" comes on, the imagination is vivid; failure 
of heart power is present early, and death is almost certain 
to follow. 



LECTURE XXI 



TYPHUS FEVER. 

Treatment. 



I have already completed the history of typhus fever, 
with the exception of its treatment, and now invite atten- 
tion to the more prominent measures which have been and 
now are employed in its management. You will notice that 
in many respects these measures are similar to those pro- 
posed for the management of typhoid fever patients, yet the 
treatment of these two diseases differs in certain essential 
particulars. When the symptoms are mild, very simple 
measures are all that is required. Of these, confinement to 
bed, cooling drinks, mild aperients, a milk diet, and free 
ventilation are the chief, and, indeed, all that is required. 
It is also important to observe the same rules in regard to 
the arrangement of the sick-room which were recommended 
in the case of typhoid fever patients. The more perfect the 
ventilation, the greater the amount of fresh air around the 
patient, the better his chances for recovery. 

The majority of cases of typhus fever are ushered in by 
active, and severe symptoms, such as would tempt one to 
adopt a vigorous plan of treatment — symptoms which at 
one time were thought to indicate the employment of heroic 
antiphlogistic measures. You must remember that these 
active symptoms are due to the effect produced on the ner- 
vous system by a poison contained in the circulating blood, 
and that this cannot be eliminated by any means of which 



244 TYPHUS FEVER. 

we have any accurate knowledge, certainly not by vomit- 
ing, pnrging, sweating, or bleeding. With these symptoms 
there is great prostration of the vital powers and a rapid 
metamorphosis of tissue. Although the symptoms seem 
urgent, and the patient has a flushed face, a rapid pulse, 
congested conjunctivae, and a high temperature, not a sin- 
gle measure must be resorted to which has a tendency to 
diminish the vitality of your patient. Dr. TVeede, of Lon- 
don, states, as the summing up of his experience upon this 
point, that although at one time he supposed bleeding and 
the so-called antiphlogistic remedies were necessities in the 
treatment of typhus fever, yet for the past ten or fifteen 
years he has not seen a single case in which depletive 
measures were admissible. 

Writers upon this disease usually consider its treatment 
under two heads — the preventive and curative. I prefer to 
use the terms prophylactic and remedial or medicinal, for I 
question our ability to cure disease. 

You can do much to prevent the development of many 
diseases, and, as guardians of the public health, this will 
constitute an important part in the active labor of your pro- 
fession. 

How, then, can you prevent the development of typhus 
fever % Medical skill cannot prevent the importation of the 
disease into localities where it is not indigenous. This is 
beyond the power of medical men, for it is controlled by 
state and national authority. Consequently typhus fever 
will probably continue to be imported into districts where it 
does not originate. 

For example, we shall occasionally see the disease in this 
city ; it may appear in any of our commercial seaports, 
and from them it may be carried into the interior. Yet we 
can do much to prevent its spread after it is imported, and 
can prevent its development as an epidemic when it is car- 
ried into any locality in the interior. It is important that 
the first case or cases of typhus fever which are developed 
in any locality should be closely watched. They should be 
immediately quarantined. The dwellings in which the fever 
has broken out should be depopulated, that is, in a tene- 



TREATMENT. 245 

ment-house in which the fever lias made its appearance, all 
tire families should be removed, and the house should be 
thoroughly disinfected. The disinfection must be thorough, 
not for a few hours, but for one or two days, and afterwards 
the house should remain open for the free circulation of air 
for a considerable length of time before persons should be 
allowed to again inhabit the rooms. Before we conclude 
the subject of treatment you will see the importance of 
following these directions. 

If typhus fever occurs in the dwellings of the wealthy, 
their houses must be quarantined. All persons must be 
prevented from visiting them, and all persons within the 
dwelling must be prevented from going abroad. After the 
sick have recovered, there must be the same thorough disin- 
fection as in the tenement house. 

All these regulations must be as carefully observed among 
the rich as among the poor. It is the rule, that though a 
person may be well fed, well clothed, and well housed, and 
be ever so cleanly, yet if brought in contact with the poi- 
son of typhus fever for a sufficient length of time he will 
contract the disease. 

Usually, in epidemics of typhus fever there are certain 
foci from which the disease spreads. Perhaps the points 
from which the contagion more especially emanates are 
within an area of half a mile square, and yet the disease 
may have been prevailing for two, three, or even four 
months. Under such circumstances it is possible to prevent 
the spread of the fever by the means just indicated. 

As far as its management in hospitals is concerned, I 
would say you should never undertake it within brick or 
stone enclosures. If possible, patients should be placed in 
broad pavilions or tents, so that the largest possible amount 
of fresh air shall be in circulation about them. It is not 
sufficient to have free ventilation in the ordinary acceptation 
of that term. The opening of a window will not accomplish 
the desired result. Remove all the windows in a room, re- 
gardless of the cold, and cover the patients with a sufficient 
number of blankets to keep them warm. Allow fresh air to 
surround them. 



246 TYPHUS FEVER. 

There are certain conditions which predispose to the de- 
velopment of typhus fever, such as the conditions cansed 
by interference with nutrition, by want of cleanliness, bad 
ventilation, want of food, and habits of intemperance. 

In Ireland, when famine occurs, then the people suffer 
most from typhus fever ; then it prevails as an epidemic. 
When it prevails epidemically in Ireland, then we are al- 
most certain to receive a certain number of cases in New 
York. 

Fatigue, anxiety, and anything which tends to lower the 
vitality of an individual render him susceptible to the in- 
fluence of typhus fever poison. Remember this, and also 
what I have before told you in regard to eating before you 
enter a ward filled with typhus fever patients. 

When the typhus fever manifests itself you can now 
understand how important it is that the guardians of the 
poor should not only enforce cleanliness, but that they 
should feed the poor better than at other times. If cleanli- 
ness is observed, the dwellings thoroughly disinfected, and 
the poor well fed, the most virulent epidemic can soon be 
stayed. The effects produced by such measures are some- 
times wonderful. 

In the year 1861, at the commencement of the epidemic, 
when, as I have before stated, the first case occurred in a 
tenement-house in one of our down-town streets, it was six 
weeks before it spread from that locality. The spread of 
the fever should have been stopped at that point ; but very 
little attention was paid to it, and it began to spread from 
one point to another, until some six or seven thousand cases 
were developed. Many of our prominent citizens sickened 
with the fever and died. This epidemic could have been pre- 
vented had measures been taken early to prevent the spread 
of the disease. It seemed to me that our city authorities 
were responsible for a large proportion of the deaths which 
occurred during the prevalence of that epidemic. 

We now come to the medicinal treatment of this disease. 

Medicinal Treatment. — As I have already stated, medi- 
cines are powerless either to arrest the progress or shorten 
the duration of this fever. 



TREATMENT. 247 

The first point which I shall discuss under this head re- 
lates to neutralizing the poison. This, many authors claim, 
can be done, and the progress of the disease thus be ar- 
rested. In my own experience I have found no medicinal 
agent which can neutralize or destroy typhus poison, or 
which has power to arrest the progress or shorten the dura- 
tion of this fever. Different remedial agents have been pro- 
posed for the accomplishment of this result, according to 
the views held in regard to the nature of the typhus poison, 
and its effects upon the system. 

At one time the mineral acids were supposed to possess 
this power, and were administered for that purpose ; but, at 
the present time, they have fallen into disuse. The internal 
use of carbolic acid, chlorine water, creasote, and more re- 
cently salicylic acid has been recommended for the same 
purpose. The inhalation of oxygen gas has also been 
thought to be of service in arresting the blood-changes, and 
thus preventing the poison from having its customary 
effect upon the system. By the stimulation which it pro- 
duces, the patient may be brought out of an apparent state 
of coma, and revive in a marked degree ; but the relief is 
only temporary. For a time the patient may improve, his 
consciousness return, and his appearance indicate that con- 
valescence is established ; but his unfavorable symptoms 
will return, and it will become quite evident that the oxygen 
has not neutralized the typhus poison. 

It seems to me that fresh air is the only thing which has 
power to neutralize the poison of typhus fever. It certainly 
possesses this power when external to the body. For ex- 
ample : place a patient sick with typhus fever in a well- 
ventilated board pavilion, or in a tent where an abundance 
of fresh air can circulate about him, and it is almost impos- 
sible for him to communicate the disease to a healthy 
person. Again, place a patient in a closed room, perhaps 
twelve by fourteen feet square, let a healthy person remain 
with him a single night — probably a much shorter time is 
sufficient — and the latter will be almost certain to contract 
the disease. Why is the disease more readily communi- 
cated in the one case than in the other? Certainly the 



248 TYPHUS FEVER. 

fresh air which circulated about the typhus fever patient 
must have prevented contagion. Fresh air, when inhaled, 
produces to a greater or less extent the same effect. You may 
say, how do we know this % It is known as a clinical fact. 
I have seen a typhus fever patient, who was apparently 
overwhelmed by the poison — perhaps within forty- eight 
hours from the commencement of the attack was in a state 
of coma, with high temperature, a rapid pulse, etc., and all 
the symptoms indicating that he was fast succumbing to 
the disease — when brought from a crowded tenement- 
house and placed in a tent, where he could inhale plenty of 
fresh air, within four or five hours from the time of admis- 
sion begin to rally, and go on to recovery. Fresh air was 
the only remedial agent employed. 

If fresh air does not neutralize the poison, it certainly has 
some effect in eliminating the poison, and thus mitigating 
the severity of the fever, and perhaps shortening its dura- 
tion. If you choose, you may regard it as a remedial 
agent, for it certainly is of greater value than any so-called 
remedial agent at our command. 

To accomplish the best results, place three or four pa- 
tients in a tent twenty feet square; the fly of the tent 
should be thrown up, and if the weather is cold, your 
patient should be well covered with blankets. By this 
means you will insure all the advantages of free ventilation. 

The question now arises, what therapeutical agents can 
be employed with advantage, in order to accomplish the 
desired results % The following are of the greatest im- 
portance : 

First. — The reduction of temperature. 

Second. — The sustaining of heart power. 

The former is of as great importance in typhus as in 
typhoid fever, and the same rules should govern you with 
regard to the agents to be employed, and the mode of their 
employment. 

As in the management of typhoid, so in the management 
of this fever, we have two antipyretic agents, namely, the 
sulphate of quinine and the application of cold to the sur- 
face. These agents may be employed separately or in con- 



TREATMENT. 249 

junction. I would here repeat a statement already made, 
that I believe quinine to be the more powerful antipyretic 
of the two agents. 

You will find that the temperature rises more quickly in 
typhus than in typhoid, after it has been reduced by the 
cold bath, and all through the early part of the fever you 
will be obliged to resort to the bath much more frequently 
than in typhoid. 

The rules for the administration of the baths in typhus 
fever differ somewhat from those that govern you in typhoid. 

In typhus fever, as soon as the temperature of the patient 
rises to 104° F., he must be placed in a bath the tempera- 
ture of which is about ten degrees below that of the patient ; 
gradually, by the addition of ice or ice-water, bring the tem- 
perature of the bath down to 68° F. or 70° F. The patient 
must be kept in the bath until his temperature falls to 101° 
F. or 102° F., then taken out, quickly dried and placed 
in bed. For some time after the removal from the bath, 
the axillary temperature will continue to fall, as the trunk 
parts with heat to the extremities. As soon as the tem- 
perature rises again to 104° F., the patient must receive 
another bath. If the patient is suffering with intense pain 
in the head, or is actively delirious during the bath, ice-bags 
may often be applied to the head with benefit. 

If the cold baths do not readily reduce the patient's tem- 
perature, or if the fall is of short duration, antipyretic 
doses of quinine must be administered, according to the 
rules given for its administration in the treatment of typhoid 
fever. 

As soon as you have passed the first week of the disease, 
having kept the patient's temperature below 103° F., usu- 
ally it will not be necessary or advisable to continue the 
baths. In most cases antipyretic doses of quinine will be 
found sufficient to keep down the temperature. Now, if not 
before, there will be evidence of heart failure, and the 
question presents itself, Shall alcoholic stimulants be admin- 
istered % In this connection I will mention the rules which 
have governed the profession in the administration of stim- 
ulants in typhus fever. 



250 TYPHUS FEVER. 

The history of alcoholic stimulants in the treatment of 
typhus fever dates back about forty years, to the teachings 
of Graves andStokes, since which time until quite recently 
they have constituted an important element in the treat- 
ment of this fever, receiving the approval of almost the en- 
tire profession. Even at the present day the habit of ad- 
ministering alcohol in large quantities in fever, and not 
unfrequently in an injudicious manner, has become almost 
universal. Most writers have regarded a frequent feeble 
pulse, with feeble cardiac impulse, even though cerebral 
symptoms may be present, as certainly indicating the ad- 
ministration of alcoholic stimulants. The directions were, 
to commence their administration early, and in sufficient 
quantities to control the pulse. It was thought that the 
earlier their administration commenced, the better the chance 
for recovery, as the failure of heart power, which makes its 
appearance in the later stages of typhus, would be pre- 
vented. No limit was given as to the quantity to be ad- 
ministered; and when typhus fever was treated in Belle vue 
Hospital, not unfrequently it was forty or fifty ounces of 
whiskey administered in divided doses within twenty-four 
hours. 

The object to be accomplished was control of the pulse. 
This could in most cases be done for a time, but as the dis- 
ease advanced, and the patient became more and more over- 
whelmed by the typhus poison, alcohol lost the power of 
giving force to the pulse. Under such circumstances, the 
rule was to give it ad libitum, for alcohol was regarded as 
the only agent by which the life of the patient could be 
saved. I remember administering from a pint to a quart of 
brandy to a fever patient within twenty-four hours. JSTow, 
what is the effect produced by the administration of large 
quantities of alcohol into the system \ 

After carefully studying for two years the action of alco- 
hol on typhus fever patients, I became convinced that in 
some patients, if not in all those who were severely ill, 
especially where there was interference with the function of 
the kidneys, its beneficial effects were doubtful, if its action 
was not decidedly injurious. That stimulants will control 



TREATMENT. 251 

the pulse and sustain the heart's action for a time, there 
can be no question ; but I found that in all severe cases 
there came a time when alcohol, in however large doses it 
was given, ceased to have this power. Besides, it must be 
remembered that large quantities of alcohol thus admin- 
istered disturb nutrition, lessen secretion, prevent the elimi- 
nation of urea, and tend to induce a state of coma which 
cannot readily be distinguished from that induced by the 
disease itself ; all of which must necessarily greatly increase 
the danger of a fatal termination. 

During the prevalence of the last epidemic of typhus fever, 
I took charge of the fever-tents on Blackwell's Island, with 
the intention of testing the effect of the withdrawal of 
stimulants in the treatment of typhus fever. 

In my earlier professional life I was thoroughly imbued 
with the idea (for I was almost born into the profession 
from a typhus fever ward) that alcohol was a necessity in 
the treatment of typhus. My house physician, Dr. Engs, 
who took the immediate care of the fever-tents under my 
direction, had had a large experience in the treatment of 
typhus fever in Bellevue Hospital, had there contracted the 
disease, and believed that his life had been saved by the free 
use of stimulants. 

As we assumed the charge of the tents I ordered that no 
stimulants nor medicines should be administered to any 
inmate of the tents. 

The cases, as they were brought into the tents from the 
city, were of as severe a type as any we had treated in Belle- 
vue Hospital ; some were in a state of coma, with an imper- 
ceptible radial pulse, and all the signs of speedy dissolution, 
— conditions which I had been educated to regard as most 
certainly indicating the free administration of stimulants. 

The rule which I established was faithfully carried out 
with the following results : While the fever was in Bellevue, 
the ratio of mortality was one death in every five ; and in 
the tents, one in sixteen. I do not claim that the great 
diminution in the ratio of mortality in the tents, as compared 
with that of Bellevue Hospital, was due to the non-adminis- 
tration of stimulants in the one case, and their free admin- 



252 TYPHUS FEVER. 

istration in the other. I do, however, most certainly affirm 
that my experiments in the tents convinced me that the 
beneficial effects which had been ascribed to the use of alco- 
hol in typhns fever were not fairly due to it. Although I 
would not entirely discard the use of alcohol in the treat- 
ment of typhus, still I would greatly limit its use and give 
it only as an occasional aid, to carry my patient over some 
peculiar time of danger from heart failure. 

Typhus fever patients under twenty-five years of age 
rarely require or are benefited by alcohol, unless they were 
of intemperate habits prior to the attack. To the old and 
feeble its occasional administration may be of great benefit, 
and at times be the means of saving life. 

A copious dark eruption, with coldness of the extremi- 
ties, specially indicates the use of alcohol. 

As a rule, delirium, headache, scanty urine, and intense 
heat of surface contra-indicate the use of alcohol. 

In any case when you decide to administer alcohol, care- 
fully watch the effect of the first few doses ; the same rules 
should govern you that were laid down for the administra- 
tion of stimulants in typhoid fever. It is impossible to give 
any positive instructions as regards the quantity of stimu- 
lants required in each case. It is very rarely necessary at 
any time during the fever to give more than eight ounces of 
brandy during twenty-four hours. If this amount will not 
sustain the heart power, I am confident larger quantities 
will fail to do it, and also that such administration has 
hastened the fatal issue. 

As soon as the symptoms, on account of which the alco- 
hol may have been resorted to, are relieved, the quantity 
must be reduced, or its administration altogether stopped. 
I do not altogether condemn the use of stimulants in 
typhus fever, but I do so as regards stimulants as a plan of 
treatment ; and, where the patient can be freely exposed to 
fresh air, I doubt if their use is often required. 

To diminish the frequency of the pulse, when it follows 
the reduction of the temperature by the application of cold 
to the surface, and the administration of quinine in anti- 
pyretic doses, cardiac sedatives have been employed, such 



TKEATMENT. 253 

as veratrum, aconite, and digitalis. The rapid pulse in 
typhus fever, after the first onset of the disease, often is 
not due to the high temperature, but to the failure of heart 
power ; when such is the case, digitalis should be em- 
ployed. Digitalis diminishes the frequency of the pulse, 
by increasing the power of the heart, and at the same time 
it increases the secretion of urine, which frequently is 
scanty, and thus, to a limited extent, becomes an elimina- 
tive. 

From four to six drachms of the infusion of digitalis may 
often be given with benefit during twenty-four hours. If 
the heart power cannot be sustained by the moderate use 
of stimulants and by digitalis given as indicated, we are 
helpless so far as remedial agents are concerned. 

The treatment of the special symptoms of typhus fever 
require only a passing notice. 

The headache, when intense, is best relieved by cold 
applications in the form of ice-bags. If it is accompanied 
by intolerance of light, a blister to the back of the neck 
will be found to give relief. 

Sleeplessness in any stage of the disease, if it continues for 
two or three days, must be relieved, for it is of itself suffi- 
cient to cause a fatal termination. If sleep does not follow 
the applications of cold to the head, opiates may be ad- 
ministered in full doses. I have seen typhus fever patients 
that had not slept for forty-eight hours drop into a quiet 
sleep within a few hours after they had been exposed to 
free ventilation. Great care should be exercised that their 
apartments are kept perfectly quiet and darkened. When 
delirium and other cerebral symptoms are associated with 
sleeplessness, hydrate of chloral may be carefully employed. 
Stupor is to be counteracted by promoting the action of all 
the excreting organs, applying external stimulants, and 
administering diffusible stimulants, the most serviceable of 
which are coffee, musk, and camphor. In the early stage 
of the disease the cold douche may be employed. 

Two remedies have been recommended for the coma of 
typhus, namely, valerian and phosphorus ; neither of these 
remedies have seemed to me to be efficacious. 



254 TYPHUS FEVER. 

When there are evidences of great prostration in connec- 
tion with any of these special symptoms to which I have 
referred, the moderate administration of stimulants may be 
resorted to, and if relief follows the first few doses their 
use may be continued. 

In the treatment of the complications which I stated to 
you were liable to occur during the course of typhus fever, 
you must be guided by general principles and by the symp- 
toms in each individual case, never forgetting that the 
primary disease has a tendency to induce great nervous 
prostration and depression, and that the heart's action 
forbids the use of all depleting remedies, and indicates a 
supporting plan of treatment. 

The pulmonary and laryngeal complications, as well as 
erysipelas, bed-sores, and gangrene, are to be managed in 
the same manner as was proposed when they occur as com- 
plications in typhoid fever. 

Diet. — This is of primary importance. Though the pa- 
tient refuse all nourishment, if possible he must be required 
or even compelled to take it. As the digestive powers are 
impaired, great care is required in selecting and administer- 
ing the proper nourishment, and it must be given at stated 
intervals, varying from one to two hours. Care must be 
taken not to over-feed — much harm may be done in this way. 
When the patient clinches his teeth and obstinately refuses 
all food, or is unable to swallow, his life may sometimes be 
saved by pouring liquid nourishment into the stomach by 
means of a long tube passed through the nose. 

Milk best serves the purpose as an article of diet. It may 
be given ice-cold, if desired, and in such quantities as the 
stomach can receive and digest. If more concentrated 
nutrition is desirable, the yolk of eggs may be beaten up 
and added to the milk. 

The management of patients during convalescence from 
typhus fever is a matter of very great importance. 

As soon as the fever ceases, most patients convalesce 
rapidly unless there is some complication, and the chief duty 
of the physician is to prevent premature exertion and ex- 
posure to cold, and to restrain the patient in the gratifica- 



TREATMENT. 255 

tion of an inordinate appetite. At this time porter or ale 
may be taken to increase the power of assimilation. The 
mineral acids, Peruvian bark, and iron may also be given as 
tonics ; these are particularly called for when the pulse is 
slow and feeble. 

It is important to guard against any sudden physical 
effort during the early period of convalescence, as it may 
lead to coagulation of blood in the veins. An opiate or 
hydrate of chloral is sometimes required to produce sleep 
during convalescence. 

In all cases great benefit will be derived from a tem- 
porary change of residence, and daily exercise in the open 
air. 



LECTURE XXII. 



RELAPSING FEYER. 

Morbid Anatomy. — Etiology. — Symptoms. —Differential 
Diagnosis. — Treatment. 

Having completed the history of typhus fever, I shall 
this morning invite your attention to the next in the list of 
contagious fevers, namely, relapsing fever. 

This is no new form of disease. It was described more 
than a century ago by Dr. Rutty, and since that time has 
prevailed as an epidemic disease in most of the countries in 
the northern part of Europe. There is no reliable history 
of its occurrence as an epidemic in this country until about 
four years ago, when an epidemic prevailed in this city. 
It has been reported that in the year 1844 a vessel landed, 
in Philadelphia, passengers ill of relapsing fever. At one 
time, while typhus fever was prevailing in Buffalo, some 
twelve or fourteen cases of relapsing fever were reported, 
but it is altogether probable that they were cases of irregu- 
lar typhus fever, for when relapsing fever has been intro- 
duced into a locality it is not limited to one or two dozen 
cases. 

Morbid Anatomy. — In this disease there are no patho- 
logical lesions of so uniform occurrence as to indicate its 
special anatomical character. In a word, there are no char- 
acteristic lesions. There are changes present in some of the 
organs which very closely resemble those that are met with 
in typhus. 

Spleen. — In the majority of autopsies, if death has oc- 



MORBID ANATOMY. 257 

curred in the active period of the disease, the spleen will be 
found considerably increased in size, the capsule thickened, 
smooth, tense, and slightly clouded, the trabecule of the 
organ increased in size, and the Malpighian tufts more 
prominent than normal. In some cases the spleen will 
be found enlarged, soft, and flabby. There is no uniform 
change in its substance, although it is always increased in 
size during the active period of the disease. After this 
period has passed it will be found diminished in size, and 
its surface will present a shrivelled appearance, with the 
corpuscles rolled into folds. In many cases a number of 
rounded or irregular miliary masses, of a dull yellow color, 
will be found. 

Liver. — During the active period of the fever this organ 
will also be found enlarged, and enlargement of the liver 
is more likely than enlargement of the spleen to remain 
after this period has passed. The structural change which 
takes place in the liver is similar to that found in the 
spleen. The urine often presents a cloudy appearance. 
The gall bladder is generally distended with dark yellow 
bile. 

Kidneys. — The kidneys will be found increased in size. 
The increase is due to congestion of the cortical substance, 
and a granular infiltration of the epithelium of the urinifer- 
ous tubules. It is a change similar to that noticed in other 
fevers. 

Intestines. — As a rule, you will find enlargement of the 
glandular follicles of the intestines. The solitary glands 
are more commonly affected, but even the Peyerian patches 
may present the "shaven-beard" appearance. The mes- 
enteric gland may be slightly enlarged, but will not present 
any change indicative of an inflammatory process, although 
there is some congestion. Its appearance is similar to that 
noticed in typhus and typhoid fevers. 

Mucous Membranes. — In the majority of cases you will 
find small spots of blood-extravasation upon the mucous 
surfaces, especially the mucous membranes of the stomach 
and intestines, and they may be found on the mucous mem- 
branes of the bronchial tubes. These spots of ecchymosis 
17 



258 RELAPSING FEVER. 

are present perhaps as constantly as any pathological lesion 
of the disease. 

Blood. — The blood coagulates imperfectly, as in typhus 
and typhoid fevers. 

The heart presents no constant changes. In some cases 
fine granular infiltration of the muscular fibres has been 
observed. This same granular infiltration is also sometimes 
seen in the voluntary muscles. 

All the other changes found are those which come under 
the head of complications. 

Etiology. — There have been wide differences of opinion 
and much discussion in regard to the etiology of this dis- 
ease. 

At the present time it seems to be the unanimous opinion 
of those who have had the best opportunities for study, 
that it is a contagious disease, and that it is a distinct type 
of fever. Although it presents many phenomena which 
ally it to typhus, and many other phenomena which ally 
it to malarial fever, it is neither typhus nor malarial, but is 
a distinct type of fever having a distinct poison. From ob- 
servations which have been made upon the blood of patients 
suffering from this fever, distinct organisms which have the 
power of developing the fever are thought to have been 
found. 

Several German observers, Cohnheim and others, have 
given drawings of these organisms, which seem to be little 
spiral lines that are constantly in motion, and these observ- 
ers tell us that they are distinctive of this form of disease, 
and are always present during its active period. They are 
absent in the interval between the primary attack and the 
relapse, but are to be seen as soon as the relapse occurs. 
With reference to these animal organisms, and others which 
are claimed to be the cause of fevers and other infectious 
diseases, while it may be true that distinct forms are 
found in different forms of fever, I question very much if 
by the introduction of these organisms into the system the 
fever can be developed. In relapsing fever, more than in 
any other, have these organisms been seen and studied, and 
yet all experimenters have failed to develop the fever from 



MOEBID ANATOMY. 259 

tliem. This fact gives those who do not believe that living 
organisms are the cause of infectious diseases a very strong 
argument ; yet, on the other hand, does nothing for those 
who hold the chemical theory of disease. 

It seems of service to those who believe that every disease 
has its own specific virus, which, as yet, we have not been 
able to distinguish either by its microscopical outline or 
by chemical analysis, but which is believed to be a subtle 
agent, similar in some respects to the venom of animals, 
and which acts upon the blood in such a manner as to cause 
the development of the living organism ; this organism can 
be seen under the microscope. 

Clinical experience has settled the question, Is relapsing 
fever a contagious disease, and can it be propagated by 
personal contagion % Some have maintained that it may be 
conveyed in the atmosphere, in water, and in clothing. 
Some of the clinical facts placed on record a few years ago, 
while the disease prevailed in Germany, go to prove that 
the fever can be conveyed from the sick to the healthy by 
means of water ; but in Ireland, where the fever seems to be 
indigenous, there is no such evidence on record. Usually 
it has prevailed in Ireland when there has been a scarcity of 
food, and on this account it has been named famine fever. 

However, the disease is not necessarily accompanied by 
starvation, for it is developed among those who are well fed 
as well as among those who are badly nourished. As in 
typhus fever, there is a connection between the development 
of an epidemic of this fever and imperfect ventilation and 
bad hygiene. 

I had never seen a case of relapsing fever until about four 
years ago, when the epidemic prevailed in New York. At that 
time patients were brought into my wards in Bellevue Hos- 
pital with a fever differing from typhus fever by the absence 
of an eruption, from intermittent in the order of its develop- 
ment, and not closely resembling remittent fever. It seemed 
to me an irregular form of malarial fever, differing from any 
form with which I was acquainted, as at that time I was 
practically unacquainted with the phenomena of relapsing 
fever. 



260 relapsing fever.- 

Eight cases were brought in. From these my house 
physician contracted the fever, and during his illness I 
reached the diagnosis of relapsing fever. Subsequently we 
had large numbers of relapsing fever patients, and a hos- 
pital was established for their reception on Hart's Island. 

In every case that occurred at that time, where the origin 
of the fever could be traced, it was found that there had been 
direct exposure, and it was established beyond doubt that 
the first cases were brought from Ireland. The contagious 
character of the affection was also established by the fact that 
all the nurses and all the physicians who were in immediate 
attendance upon the sick contracted the fever. If a patient 
was placed in a bed before it had been cleaned, previously 
occupied by a person sick with relapsing fever, he was 
almost certain to contract the disease. At the time of this 
epidemic we found no evidence that the fever was conveyed 
by clothing, although some British writers have claimed 
that it can be done. When our patients were admitted into 
the hospital, their clothing, as it was removed, was simply 
washed, not disinfected in any special manner, then packed 
away, and not a single person who was thus brought in im- 
mediate contact with the clothing contracted the disease. 
The period of incubation ranges between ^.ve and seven 
days. 

Symptoms. — The symptoms which usher in relapsing 
fever are usually well marked. It is sudden in its advent. 
This is marked by a severe rigor or by a distinct chill. Ac- 
companying the chill there is a frontal headache, pain in 
the limbs, more or less pain in the back, nausea, and not 
infrequently vomiting. A rapid rise in temperature follows 
the chill, and with its appearance the headache increases, as 
does also the pain in the limbs, especially about the joints. 
There is vomiting, at first only of the simple contents of the 
stomach, afterwards of yellowish material. This may be 
followed by the ejection of a dark-colored material, which 
very closely resembles the black vomit of yellow fever. 

In this disease, the rise in temperature is always rapid, 
and usually marks its highest point within the first twenty 
four hours ; during this time it may rise from 98^° F. to 



SYMPTOMS. 261 

104° F., or even as high as 109° F. From this time, for two 
or three days, there is usually very little variation. With 
the occurrence of the chill and fever there is also a rapid 
increase in the frequency of the pulse. In no disease does 
the pulse so quickly become rapid as in relapsing fever. It 
is not uncommon for it to reach 140, 150, or even 160 beats 
per minute within the first twenty-four hours. It is usually 
small and compressible. 

There is nothing peculiar about the countenance of the 
patient, but it presents the ordinary appearance noticed in 
an active febrile excitement. 

As the disease progresses the patient becomes more and 
more prostrated ; by the second day he may be unable to 
turn in bed. The arthritic pains increase in severity, and 
often become the most distressing symptoms of the fever. 
As early as the second day, patients begin to complain of a 
feeling of weight and uneasiness in the upper part of the 
abdomen, more severe in the left than in the right hypo- 
chondrium. Usually there is considerable enlargement and 
tenderness of the liver. The spleen also becomes rapidly 
enlarged, and its enlargement is attended with quite severe 
pain and tenderness. The muscles of the body are, how- 
ever, the seat of the most severe pain, which is increased by 
movement and by pressure ; the pain is piercing and lancinat- 
ing in character. On account of this pain, the patient usually 
lies perfectly quiet ; he is not restless, but sleepless. Deli- 
rium is not an unfrequent symptom, and is sometimes very 
active, yet in the majority of moderately severe cases the 
mind remains undisturbed. There may also be present 
irregularities of the pupils, photophobia, and other symp- 
toms which might lead you to the diagnosis of meningitis 
were it not for the character of the pulse. 

As the disease progresses, in a certain proportion of cases 
jaundice is developed ; this is usually accompanied by vomit- 
ing and severe diarrhoea, and these symptoms seem to ally 
the disease to some forms of malarial fever. 

The great prostration and rapid rise in temperature ally 
it to typhus fever, but the rise is more rapid and reaches a 
higher point within the first twenty-four hours than it does 



262 RELAPSING FEVER. 

in typhus fever. There is sometimes a slight rose-colored 
eruption resembling roseola, but having none of the char- 
acteristics of typhus eruption. The patient goes on from 
day to day gradually getting worse, the fever becomes more 
and more intense ; loss of strength and emaciation is pro- 
gressive, and the muscular pains are more severe. You 
may have been watching your patient with the greatest 
anxiety, the pulse has reached 160 per minute, the tongue 
is brown and dry, extreme nausea and vomiting are present, 
and the severity of the symptoms indicate that death may 
speedily occur, when, on the seventh or eighth day of the 
fever, suddenly a remission occurs, attended by a profuse 
perspiration. With the occurrence of the profuse sweating 
the temperature falls ; in a few hours it may fall five, six, or 
even seven degrees ; the pulse becomes less frequent ; the 
respirations, which have been hurried and difficult, become 
regular ; the pains in the head and limbs pass awaj^, the 
thirst disappears, the tongue becomes moist ; the engorge- 
ment of the liver and spleen rapidly diminishes, as is shown 
by the rapid diminution in the size of these organs, which 
is readily determined by percussion. 

Within twelve hours from the commencement of the re- 
mission, the temperature may fall to less than 100° F., per- 
haps below the normal standard, and the pulse may fall to 
80 or 90 beats per minute. 

Sometimes, instead of a profuse perspiration taking 
place at the commencement of the remission, a profuse 
hemorrhage from the nose, the bowels, or uterus may 
occur. 

As soon as the remission occurs the patient feels perfectly 
well, except a sense of weakness. He gets out of bed, and, 
if he is in a hospital, perhaps insists upon his discharge ; 
his appetite begins to return, and he appears to be rapidly 
convalescing. 

His apparent convalescence is of short duration ; some- 
times in three or four days, usually at the end of a week, 
certainly by the twelfth or fourteenth day of the disease, 
all the phenomena of the primary fever are suddenly de- 
veloped, or what is termed the relapse occurs. Sometimes 



SYMPTOMS. 263 

the relapse occurs in the morning, sometimes in the after- 
noon, but more frequently it comes on at night. 

The relapse may be ushered in by a chill, or it may occur 
without a chill. The pulse may begin to increase in rapidity 
and in twelve hours reach 140 per minute. With the rapid 
pulse, the temperature rapidly rises to 160° F. or 170° F. 
and even as high as 180° F. Usually the fever which at- 
tends the relapse is more intense than the primary fever, 
the liver and spleen become as enlarged as during the pri- 
mary fever. 

It is claimed by some observers that the parasites which 
are said to be present in the blood during the primary fever, 
disappear during the remission, but reappear in greater 
numbers during the relapse. The relapse usually lasts 
three or four days. In a few cases I have seen it last six 
or seven days, and in some it does not continue more than 
forty-eight hours. After it has continued a certain period, 
a second remission is developed ; this, like the first remission, 
comes on suddenly, is accompanied by a profuse perspira- 
tion, and in twenty -four hours from its commencement the 
pulse and temperature have reached their normal standard. 
From this period, the patient usually goes on to complete 
recovery. 

As many as three or four relapses may occur, but ordi- 
narily the convalescence becomes complete after the second 
remission. 

Convalescence from relapsing fever is usually rapid, but 
the patient for a long time remains in a weak condition, 
suffering more or less from arthritic and muscular pains. 
The appetite returns slowly. An anaemic murmur, which is 
often very distinct during the active period of the fever, 
is heard for two or three weeks after the commencement of 
convalescence. (Edema of the feet, due to general anaemia, 
is often quite marked during convalescence. 

The period of convalescence is usually as long as both 
the period of fever and remission ; not unfrequently six or 
eight weeks elapse before relapsing fever patients are able 
to resume their accustomed avocations. 

At the commencement of convalescence, the decrease in 



264 RELAPSING FEVER. 

the size of the spleen is rapid, but frequently it is a long 
time before the organ reaches its normal size. 

Complications. — Few complications have been noticed 
during the course of relapsing fever. In some epidemics 
pneumonia has occurred quite frequently; at other times it 
has been exceedingly rare. When it does occur, it is often 
double. 

Sudden collapse may occur as a complication of relapsing 
fever, either during the primary fever or during the relapse. 
The pulse suddenly becomes small, irregular, or inter- 
mittent, sometimes imperceptible. The cardiac impulse is 
feeble, the heart sounds are lost, and the patient rapidly 
passes into a condition of collapse, and dies. The collapse 
may come on suddenly in cases previously mild. 

Post-febrile ophthalmia is another very remarkable com- 
plication or sequela of this fever. It has been observed in 
most epidemics. It presents two distinct stages, the amau- 
rotic and the inflammatory. During the first stage the 
patient complains of impaired vision, with motes and lumi- 
nous circles floating before the eyes. The inflammatory 
stage is characterized by intense circumorbital pains and 
lacrymation, without injected conjunctivae or marked con- 
stitutional disturbance. Recovery is tedious, and, unless 
the case is carefully treated, may end in complete loss of 
sight. Both eyes are rarely attacked ; the right eye is 
most frequently affected. 

Diarrhoea and dysentery are common complications, and 
in some epidemics they are the chief cause of death. They 
are most likely to come on during the relapse. In our 
epidemics the most frequent complication is hemorrhage 
from the mucous surfaces, especially from the stomach and 
intestines. In two cases that came under my observation 
hemorrhagic pachymeningitis was the cause of death. In 
very rare instances, abscess of the spleen, accompanied by 
pyemic symptoms, have occurred during the relapse and 
convalescence. 

Pregnant females, no matter at what stage of pregnancy, 
usually abort during an attack of relapsing fever. 

Differential Diagnosis. — The diagnosis of relapsing 



peog^osis. 265 

fever is not difficult if you have the entire history of the 
case ; but, at the commencement of an epidemic, during 
the primary fever, you will necessarily be in doubt as to 
your diagnosis. 

The diseases with which it is possible to confound relaps- 
ing fever are typhus, typhoid, remittent, yellow, and den- 
gue fever, small-pox (before the eruption), and measles. 

It differs from all these diseases in the suddenness of its 
invasion, in the short duration of the primary fever, and in 
its termination in a crisis, and in the almost uniform occur- 
rence of a relapse between the third and fifth days. 

Then the muscular and arthritic pains, which are such 
constant attendants of relapsing fever, distinguish it from 
the other forms of fever. 

A severe form of relapsing fever, attended by jaundice, 
resembles very closely, in its general appearance, yellow 
fever ; but the high temperature and rapid pulse which 
attend the development of the former readily distinguish it 
from the latter ; besides, when the relapse comes on, there 
can no longer be any question as regards diagnosis, for 
yellow fever is a disease in which a relapse rarely occurs. 

Small-pox simulates relapsing fever only during the 
period of invasion. You need make no doubtful diagnosis 
after the third day, when the red spots appear along the 
edges of the hair. 

Pbognosis. — The prognosis in relapsing fever is always 
good. During our epidemic about three per cent, of all the 
cases treated in hospital terminated fatally. This is a lower 
rate of mortality than we have with measles. Usually deaths 
from relapsing fever occur, not from the disease, but from 
some complication. During the epidemic in this city, syn- 
cope during relapse was the most frequent cause of death. 

Relapsing fever patients may die of hemorrhage from 
some of the mucous surfaces. A fatal termination may 
occur from bronchitis, pneumonia, or other pulmonary 
complications. During one Russian epidemic parenchyma- 
tous hemorrhage was a frequent cause of death. 

Diarrhoea and dysentery occurring during convalescence 
sometimes cause a fatal termination. 



26(5 EELAPSING FEVER. 

Sudden suppression of urine dependent upon renal con- 
gestion may give rise to acute uraemia, and thus cause 
death. 

My own experience leads me to the belief that the great- 
est danger in this disease arises from sudden syncope. I 
remember one very marked case, that of a young physi- 
cian, who seemed to be doing well in his second relapse, 
when suddenly he passed into a state of syncope and died. 
At the post-mortem examination no condition of the in- 
ternal organs was found which would account for his 
death. 

Treatment. — Dr. Reilly, who wrote upon this disease 
more than a century ago, stated that all those cases of re- 
lapsing fever which were abandoned to whey and the good 
providence of God, recovered. The experience of a century 
has furnished no accepted plan of treatment. The profes- 
sion are still unsettled as to the best course to be adopted 
in the management of this disease. 

When this fever appeared in our midst, we thought we 
could control it by large doses of quinine, but we soon found 
that quinine was of no service in its treatment. Then 
aconite and veratrum were employed in full doses as anti- 
pyretics, but after a time these were abandoned as useless. 

Cold baths were resorted to, as also was sponging of the 
surface in order to reduce the temperature, but in their use 
we were disappointed. The temperature was reduced while 
the cold was being applied, but rose again very soon after 
the patients were removed from the baths, and there was no 
effort made to diminish the severity or shorten the duration 
of the primary fever, or prevent the occurrence of the relapse. 
Opium in full doses was then tried, but with equally un- 
satisfactory results, although its free use was found to give 
more comfort to the patients than did any other plan. 

In some cases stimulants were administered quite freely, 
but without any apparent beneficial results. 

The conclusion arrived at was, that relapsing fever pa- 
tients were as well without as with medication. I would 
insist that relapsing fever patients should be kept quiet 
in bed during the primary fever, and should not be allowed 



TBEATMENT. 267 

to leave their rooms until the period of relapse shall have 
passed, and that the greatest care should be exercised to 
guard against the occurrence of syncope. If there is evi- 
dence of he-art failure, digitalis and stimulants should be 
administered according to indications. More than this I 
have nothing to suggest. My experience leads me to place 
relapsing fever patients under the best hygienic manage- 
ment, with free ventilation and a mild diet, and then care- 
fully watch lest some complication should occur. 



LECTURE XXIII. 



EXANTHEMATOUS FEVERS. 

Small-Pox. — Morbid Anatomy. — Etiology. — Symptoms. 

This morning I shall commence the history of the exan- 
thematous fevers. They are three in number, small-pox, 
scarlet fever, and measles, or variola, scarlatina, and rube- 
ola. These are distinct diseases, more markedly so than 
any of the varieties of fever which have been engaging our 
attention. 

Some writers, not regarding them as distinct diseases, 
have described them under the general head of acute exan- 
thematous diseases. It seems to me that they should be 
included in the list of fevers : first, because they are infec- 
tious, and depend for their development upon distinct poi- 
sons as specific in their nature as those that develop typhus 
or typhoid fever ; second, for the reason that active febrile 
symptoms attend their development and mark their pro- 
gress ; third, because they run a definite course, one marked 
by regular stages of development and decline, and with rare 
exceptions they attack the same person but once. 

I shall speak first of small-pox or variola. Since the day 
of Jenner's wonderful discovery, small-pox has not occu- 
pied the. attention of the profession as it did previous to 
that time. Prior to this discovery, small-pox was dreaded 
like the plague, and when it did prevail, cities, and often 
whole countries, were depopulated by it. With the discov- 
ery of vaccination, a new era was developed in its history. 
During the present century epidemics of small -pox have 



MORBID ANATOMY. 269 

not been greatly feared. During the past six or eight 
years, however, this disease has been on the increase, and 
the death records in this city show that some years there 
have been more deaths from small-pox than from either of 
the other exanthematons fevers. Why this great increase, 
is a question worthy of careful consideration. It cannot be 
from any failure in the protective power of the means which 
we possess for preventing its development, but from the 
imperfect manner in wdiich such means are employed. Vac- 
cination, properly performed, is a perfect protection against 
its development. The truth of this statement no one of ex- 
tended experience w r ill question, although vaccination, as 
formerly practised in this city, seemed to fail to protect the 
masses from the contagion of small-pox. 

I shall consider this part of its history more fully under 
the head of vaccination. 

I will now call your attention to the anatomical lesions 
of small-pox. Besides those which occur upon the mucous 
membranes and skin, congestions of the internal organs 
may be regarded as the most prominent. The anatomical 
changes wmich occur in all cases will vary in degree, if not 
in kind, with the type of the variola. 

Three distinct types of this disease are recognized, to 
which have been given the names "variola discreta" " va- 
riola confluens" and "variola hemorrhagica." 

Morbid Anatomy. — You will rarely make a post-mortem 
examination upon one who has died of small-pox, without 
finding more or less intense congestion cf the lungs, the 
brain, the liver, the spleen, and the kidneys. 

Perhaps the most constant lesions affecting the viscera 
are parenchymatous degenerations ; sometimes these are 
simply granular infiltrations, at other times they consist of 
an acute fatty degeneration, resembling that produced by 
phosphorous poisoning ; this is really a fatty infiltration. 

If the liver and kidneys are far advanced in fatty change, 
the walls of the heart will usually be found yellow, flabby, 
and brittle. 

In the hemorrhagic form of small-pox, besides these 
changes you will find small hemorrhages in nearly all the 



270 SMALL-POX. 

viscera, with, ecchymoses of the serous membranes and fluid 
blood in the cavities. Every mucous membrane may be the 
seat of a hemorrhage. 

The characteristic anatomical lesion of small-pox is to 
be found upon the mucous membranes and upon the skin. 
This lesion is usually spoken of as the eruption. It does 
not differ essentially in the different varieties of the disease ; 
the modifications which are met with are due rather to its 
duration and order of development than to any difference 
in the anatomical changes. 

If we study closely these surface lesions, we will find 
that they pass through regular stages of development and 
decline. The first change that is noticed looking towards 
the development of this lesion is congestion of the papillae. 
In some cases this congestion seems to occur in spots, while 
in other cases it is quite uniform. The congestion of the 
papilla3 gives rise to the little red spots upon the surface, 
which are the first to mark the development of the eruption. 
The papillae, which are the seat of the congestion, will very 
soon be found to be surrounded with cells, which are larger 
than those seen in the normal tissue of the part. These 
cells very rapidly undergo granular degeneration. Most of 
these cells have escaped from the blood-vessels or are 
changed tissue-cells. As these new cells accumulate, they 
cause the epidermis to become elevated, and as the result of 
the elevation we have a little papule formed at the point of 
redness. The papules which are formed at the red point 
are due to the changes in the surrounding cells, changes in 
the rete-Malpighii and in the capillaries, and also to a 
certain extent to new-cell infiltration. 

After these changes have taken place, you will notice a 
serous infiltration upon the surface of the papule, or per- 
haps into its substance. This serous fluid is simply the 
serum of the blood which has escaped through the walls of 
the congested capillaries, and formed upon the top of the 
papule a little elevation which is recognized as a vesicle. 

In a certain proportion of cases, you will find that, soon 
after the vesicle begins to form, its centre becomes de- 
pressed. This depression or umMUcation, as it is usually 



MORBID AX ATOMY. 271 

called, lias been accounted for in different ways by different 
observers. 

Some explain it by saying that each papule and subse- 
quent vesicle holds imprisoned at its centre either a hair- 
follicle or the duct of a sweat-gland, and that when this 
epidermidal layer of the papule is elevated by the serous 
exudation or infiltration, the portion immediately about the 
hair-follicle or the sweat- duct is held down, and a depres- 
sion is produced at the exact point where the hair-follicle 
or duct of the gland maybe situated. Another explanation 
(which I regard the better one) of the umbilication of the 
vesicle is, that the serous infiltration takes place more 
rapidly at the periphery of the vesicle than at its centre ; 
consequently, the former becomes more elevated than the 
latter. 

Umbilication of the vesicle is by no means of constant 
occurrence, as can be readily ascertained by close examina- 
tion of a number of vesicles. 

We have considered fchose anatomical changes which take 
place in the papule and vesicle. Now another process com- 
mences, pus-cells or white blood-globules from the capilla- 
ries migrate into the surrounding tissues and into the 
vesicles, and as a result the vesicles change in color. In 
other words, the vesicles become changed into pustules. 
At the same time an inflammatory process, more or less ex- 
tensive, is going on in the walls of the pustule, and in the 
surrounding cellular tissue, which terminates in a destruc- 
tion of tissue at the point where the papillary congestion 
first occurred. If only the superficial layer of the skin is 
involved, the infiltration of pus-cells into the vesicle and the 
formation of the pustule may take place without extension 
of the inflammation into the cellular tissue beneath, and 
necrosis or death of the part will not follow ; but, if you have 
the inflammation extending into the deeper tissues, a slough 
will be produced, which necessarily will be followed by a 
cicatrix and pitting. 

Remember that pitting is the result of a slough that has 
been produced by an extension of the inflammatory process 
into the deeper tissues. 



272 SMALL-POX. 

When the cellular tissue becomes involved in inflamma- 
tion it readily undergoes the sloughing process. This is 
the reason why we have pus so readily formed and in such 
quantities, when in any paft of the body an apparently 
slight degree of inflammatory action invades this tissue. I 
dwell upon this point, for it has a bearing upon the treat- 
ment of the pustule, for which a long list of remedies has 
been proposed with the view of preventing pitting. Pre- 
vention of pitting will depend upon the extent of the inflam- 
matory process; if it involves the cellular tissue, pitting 
will follow in spite of all the applications that may be made. 
You may prevent pitting if you can find any means of arrest- 
ing the inflammatory process before it involves the cellular 
tissue. After the pustule is formed the inflammatory pro- 
ducts begin to dry down, and a crust is formed which con- 
tracts in the central portion, and the same umbilicated 
appearance is presented that is seen in the umbilicated 
vesicle. After a time these crusts are separated by the or- 
dinary changes which occur in the subsidence of an inflam- 
matory process, and recovery is complete, except that there 
is left behind a cicatrix, which undergoes the same changes 
as does a cicatricial tissue formed under any other circum- 
stances. 

I have now briefly described to you the anatomical lesions 
of a variola pustule. I would add that these pustules may 
be formed upon any of the mucous membranes of the body. 
They are also frequently formed upon the mucous membrane 
of the stomach, intestines, bronchial tubes, larynx, and 
upon the conjunctivse. The surface of the body is the place 
where they are most abundantly developed. The anatomi- 
cal changes which take place in the skin and mucous 
surfaces are similar to those which attend any ordinary in- 
flammatory process. These inflammatory processes are set 
up by a specific small-pox poison, which carries with it a 
tendency to produce destruction of tissue at the point where 
the inflammation is established. In the milder forms of 
small- pox, pitting does not occur, but in severe forms it is 
always present to a greater or less degree. 

There is nothing specific or essentially different in the 



ETIOLOGY. 273 

development of the pustules in hemorrhagic small-pox 
from their development in the ordinary forms of the disease ; 
the only difference is, that their contents are bloody instead 
of serous or purulent. 

In the hemorrhagic variety, larger or smaller hemorrha- 
ges take place into the cellular tissues ; in the milder forms 
they take place only in the layer beneath the papillae ; 
while in the severer forms they take place beneath all the 
cutaneous layers ; even the subcutaneous fat may be infil- 
trated with, blood. No changes in the walls of the vessels 
have as yet been discovered which will account for these 
hemorrhages. These extravasations more frequently occur 
in those cases in which death takes place before the period 
of pustulation is reached. 

Etiology. — The etiology of small-pox is a subject which 
at different times has engaged the attention of the profes- 
sion. At the present day the opinion is almost universal 
that the disease is propagated only by contagion ; that is, 
that it is a disease which can only be produced by its own 
specific poison, and is communicable only to persons who 
are not protected from its influence. 

There has been considerable question as to where the vi- 
rus of small-pox is located. Some claim that it is exclu- 
sively in the pustule, and that it is not possible for a person 
suffering from small-pox to give the disease to an unpro- 
tected individual unless some of the virus from the pustule 
is brought in contact with a cutaneous or mucous surface. 

This is a mistake. That small-pox can be conveyed by 
means of virus taken from a pustule there can be no ques- 
tion ; but you may rub the cutaneous surface of an unpro- 
tected person with pus taken from a small-pox pustule, and 
unless there is an abrasion of the surface the poison will 
not enter the body and the person will not become inocu- 
lated with the disease ; but if you place the virus in contact 
with a mucous membrane of an unprotected person he will 
almost certainly contract the disease. It is equally certain 
that the disease can be communicated from one person to 
another by means of the breath and exhalations from the 
skin. There is no evidence that the disease can be con- 
18 



274 SMALL-POX. 

veyed by the discharges from the bowels. Perhaps if a 
pustule should be developed somewhere along the line of 
the intestine the discharges may become so contaminated as 
to have the power of communicating the disease. 

Small-pox can also be conveyed from one individual to 
another through the atmosphere. In the open air the dis- 
tance of contagion is about two and one -half feet. In a 
small room the atmosphere may be so contaminated that 
an unprotected person will contract the disease upon a 
single entrance into the room. 

The disease can be conveyed in clothing, and the poison 
will remain for a long time in clothing, unless it has been 
exposed for a considerable time to the air. In other words, 
there is no doubt but that it is a portable disease. In order 
that the disease may be transferred by means of the clothing 
or merchandise, it is necessary that the clothing or mer- 
chandise contain the pus or crusts from the small-pox 
pustules ; how long a time may elapse before the virus loses 
its vitality is not known. There are well -authenticated 
cases in which it has retained its virulence for more than a 
year. 

No period of life is exempt from the contagion of small- 
pox ; even intra-uterine life is in danger from infection. 
Rarely does an individual have a second attack. I remem- 
ber one exception, that occurred in the person of a young 
Swedish woman, who under my observation passed through 
three well-developed attacks of the disease ; the last attack 
was the most severe. 

Concerning the exact nature of the small-pox virus 
nothing definite is known. 

Some observers claim that the earliest period at which 
one suffering from this disease can infect the unprotected is 
the period of suppuration. Others claim that the infecting 
period is during the stage of desiccation. There are well- 
authenticated cases, however, which prove to us that infec- 
tion may take place during any stage of the disease, even 
during the period of incubation. There is little doubfc but 
that the suppurative stage is the most infectious period. 

There are differing views as to the manner in which the 



SYMPTOMS. 275 

small-pox poison gains entrance into the system ; the most 
probable of these views is, that it is principally absorbed 
by the mncons membrane of the respiratory track during 
respiration, and it is also probable that exceedingly line 
particles detach from the pnstnles and crusts, which are 
suspended in great numbers in the air surrounding small- 
pox patients, and that these convey the contagion. There 
are no facts to sustain the recent views as to the parasitic 
nature of this contagion. 

The length of time which elapses after exposure to, and 
reception of, the variola contagion before the disease is de- 
veloped varies from ten to thirteen days. This is called the 
period of incubation, during which the recipient of the 
poison usually presents no abnormal symptoms. If the 
poison is introduced into the system through inoculation, 
only forty-eight hours elapse before the characteristic phe- 
nomena of the variola are manifested. It is not known 
what change takes place in the body of the infected person 
during this period of incubation. Usually, twelve days 
after exposure, the person who has contracted small-pox 
begins to feel chilly ; this feeling of chilliness increases until 
he has a distinct chill. This has been termed the initial 
stage, or the stage of initiatory fever. 

Symptoms. — The transition from the stage of incubation 
to that of initiatory fever is sometimes abrupt and some- 
times gradual ; usually it occupies two days and is fol- 
lowed by the eruption. In this stage there is greater vari- 
ation in the intensity than in the duration of the symptoms. 
The intensity of the symptoms bears no relation to the 
severity of the attack. Not unfrequently, the most violent 
symptoms in the initial stage are followed by a mild attack 
of variola ; while mild symptoms in the initial stage are fol- 
lowed by the gravest form of small- pox. With the chill, 
which may be more or less severe, there is severe pain in 
the head and back, especially in the middle of the back ; 
with this pain there will be a rapid rise in temperature. 
During the first day the temperature may rise to 104° F., 
during the second day to 105° F., and by the third day it 
may reach 106° F. or 107° F. ; in some cases it has been 



276 SMALL-POX. 

said to have readied 109° F. With this rise in temperature 
there will be an acceleration of pulse ; it may reach 100 or 
120 beats per minute. In the strong and robust person, the 
pulse will be full and not easily compressed. In females, 
and in the weak and feeble, the pulse has less volume, but 
usually is more frequent ; it may reach 140 beats per 
minute. 

At the very onset of the disease, the pulse become mark- 
edly increased in frequency, and the temperature becomes 
very much elevated. 

At this period, usually, there is more or Jess nausea and 
vomiting, and there will be soreness of the throat. This 
soreness of the throat may have preceded the chill by 
twenty-four hours, but now in many cases it will be quite 
severe, and the patient will complain of more or less difficulty 
in swallowing, and of pain in the pharynx. The extent of 
the trouble in the throat will depend upon the severity of 
the attack. 

In the severer forms of the disease, by the third or even 
before the end of the second day, there may be delirium. 
In all cases, the face will be flushed, the conjunctivae con- 
gested, and there will be throbbing of the carotids. With 
these symptoms, there will be great restlessness, and an 
anxious expression of countenance, with somnolence. The 
respirations will be short, frequent, and labored. Many 
suffer from extreme vertigo, and in children convulsions are 
not infrequent. By the evening of the second, or morning 
of the third day, usually swelling and diffuse redness of the 
tonsils and soft palate are present ; not unfrequently the 
swelling and redness of the mucous membranes extends into 
the larynx, causing hoarseness and huskiness of the voice 
and a stridulous cough. 

Some writers describe an initial erythematous rash which 
precedes the eruptive stage of small-pox. This rash is so 
rarely met with in this country that it seems to me to be an 
accidental occurrence rather than a symptom of the initial 
stage of the disease. 

During the fever of invasion patients are languid and 
weak in proportion to the severity of the fever. • Fre- 



SYMPTOMS. 277 

quently, within twenty-four hours, after the ushering-in 
chill the strongest and most vigorous will be unable to get 
out of bed- 
There is always loss of appetite ; nausea and vomiting are 
frequently present. If vomiting occurs it is present at the 
very beginning of the initial fever, and continues with great 
obstinacy throughout its entire course. In the hemorrha- 
gic variety the matters vomited may contain blood. 

Stage of Eruptions. — By the third day of the disease, at 
least after the initial fever has continued three full days, 
an eruption will make its appearance upon the face, espe- 
cially along the edges of the hair. 

I will describe the eruption as it develops in a moder- 
ately severe case of discrete variola. It first appears in the 
form of slightly elevated maculaB. These are of a pale red 
color, varying in size from a millet-seed to a pin's head, or 
even larger. These little red spots look very much like flea- 
bites. In most cases the forehead, nose, and upper lips are 
covered first. If you closely watch them you will find that 
they gradually increase in size ; the increase is attended by 
a sensation of itching and burning of the surface. Usually, 
about twelve hours after their appearance upon the face, 
similar small red points appear upon the body and extrem- 
ities ; first on the body, then on the legs and arms, and 
lastly on the hands and feet. They are always less abun- 
dant on the body and extremities than on the face. On the 
second day of the eruption these spots assume a darker 
red color, become elevated and distinctly papular. On the 
third day they become more conical in shape, and at their 
apex a vesicle is formed, which gradually enlarges until the 
fourth or fifth day, when they reach the size of a small pea, 
and are spherical in shape. 

In a majority of instances, as they enlarge, a depression is 
formed, which gives to them an umbilicated appearance. 
At the centre of the depression the opening of a hair- 
follicle or sweat-gland will often be found. The appear- 
ance of eruption is attended by a subsidence of the febrile 
symptoms, the patient no longer complains of pains in the 
head and back, the temperature falls two or three degrees, 



278 SMALL-POX. 

and the pulse diminishes fifteen or twenty beats in fre- 
quency. 

Stage of Suppuration. — About the sixth day of the 
eruption the contents of the vesicle, from the admixture of 
pus-corpuscles, gradually become turbid, and by the eighth 
day the pustules become fully formed, and the disease en- 
ters on the stage of suppuration. The integument in the 
immediate vicinity of the pustule now becomes red and 
tumefied, each pustule being surrounded by a broad red 
base, and where they are thickly set they become conflu- 
ent. The face swells to a shapeless mass, and the patient 
becomes frightfully deformed. The itching now becomes 
almost unbearable, and causes the patient to scratch him- 
self, thus causing ultimate disfigurement. During this pe- 
riod a characteristic sickly odor is emitted. 

As I have already stated, the eruption appears on the 
trunk and extremities a day or two later than on the face, 
and on these parts it passes through its stages two or three 
days later than it does on the face ; consequently, suppura- 
tion may be complete on the face while it is still taking 
place on the extremities, and the eruption may be perfectly 
discrete on the trunk, while it is confluent on the face. 

About the eighth or ninth day of the eruption the pus- 
tule is fully formed ; the stage of suppuration is complete. 
Then commence the retrograde changes. The pustule either 
ruptures, discharges its contents, dries up and forms a yel- 
lowish crust, or it shrivels and dries up without rupturing. 

This is called the period of desiccation. 

Stage of Desiccation. — Desiccation commences in those 
parts in which the eruption first appeared. As the drying 
down of the pustules takes place, the redness and tenderness 
of the skin lessens, and the countenance begins to assume a 
more natural appearance. At first the crust adheres quite 
firmly to the surface, but between the eleventh and four- 
teenth day of the eruption it is separated from the surface 
and falls, leaving a stain of a reddish- brown color, with ele- 
vated edges and depressed centre, which remains visible for 
five or six weeks. These spots gradually become lighter in 
color, until finally, if there has been destruction of the 



SYMPTOMS. 279 

cutis, a pit will be formed of greater or less depth, of a 
white color, giving to the face a f ' pock-marked ' ' appear- 
ance, which will remain during the life of the individual. 

I have already stated to you that the febrile symptoms 
gradually increase in severity until the third day of the dis- 
ease, when the eruption appears and the fever subsides. 
Then the vesicles form, the formation of which is attended 
by only moderate fever. On the eighth day the pustules 
are fully formed, and the suppurative, or, as it is called, the 
secondary fever comes on. This secondary fever often 
commences with a distinct chill, the pulse becomes frequent, 
the temperature rapidly rises, perhaps reaches a higher ele- 
vation than it did during the initial fever, sometimes rising 
as high as 108° F. or 109° F. ; it reaches its maximum when 
suppuration is at its height. As desiccation commences, 
the temperature begins to fall, and by the time the crusts are 
fully formed the temperature reaches very nearly a normal 
standard. If the temperature rises again, its rise is due to 
some complication, such as erysipelas or some phlegmonous 
process. With the fall of the crusts, the patient's appetite 
returns and he is able to sleep ; convalescence is now fully 
established. 



LECTUKE XXIV. 



SMALL-POX 



Symptoms {continued). — Differential Diagnosis. — Prog- 

nosis. 

I have already given you the history of the symptoms of 
an ordinary case of discrete small-pox. This may be regarded 
as a prototype of all varieties. This morning I shall call 
yonr attention to the points of difference between the other 
varieties of small-pox and that variety whose history we 
have been considering. The dividing lines between these 
different varieties are not sharply defined ; one variety grad- 
ually passes into another variety. 

It is unnecessary for me to consider all the forms into 
which this disease has been divided by medical writers ; 
frequently the basis of the division is merely arbitrary. We 
will therefore confine our attention to the more common 
and well-recognized varieties. 

Confluent Small-pox, or Variola Confluens. — This is a 
much more severe form of the disease than variola discreta. 
It develops far more rapidly and is much more fatal in its 
results. 

The fever of invasion is usually much more severe, and of 
shorter duration, frequently not lasting more than forty- 
eight hours. The eruption spreads rapidly over the entire 
body, often appearing simultaneously on the face and the 
other portions of the body. The red dots which mark the 
first appearance of the eruption are very numerous, especially 
on the face and hands ; on the first day of their appearance 



SYMPTOMS. 281 

they are almost confluent. On the second day the skin is 
intensely red and swollen, and so thickly studded with 
large flat vesicles that they rapidly unite, suppuration 
speedily follows, and flattened, yellowish- colored confluent 
patches are formed upon a dark, reddened, swollen skin. 
Gradually these patches run together over a still larger sur- 
face, and the epidermis is elevated in the form of large, flat 
bullae, which are filled with a sero-purulent fluid. In this 
way the entire skin of the face is covered by an immense 
bulla, and the patient is as unrecognizable as though he wore 
a mask. While the eruption may be completely confluent 
on the face and hands, on other parts of the body it remains 
distinct, and never becomes confluent except over limited 
spaces. 

The period of desiccation is slowly reached. Large con- 
centric crusts are formed over the confluent patches ; these 
adhere firmly to the skin, while beneath them suppuration of 
the papillary layer continues. The trne skin is more or less 
extensively destroyed, and when the crusts have fallen, there 
is left extensive loss of substance in the cutis, giving rise to 
pits and ugly scars, which have a tendency to contract, often 
producing permanent and unsightly disfigurements. In this 
variety of small-pox, the eruption is often confluent upon 
the mucous membrane of the mouth and throat ; it may in- 
volve the mucous membrane of the posterior nares, and ex- 
tend into the larynx. In some cases the attending pharyn- 
gitis is so severe as to render deglutition impossible. The 
pharyngeal inflammation is submucous, and is frequently 
accompanied by more or less enlargement of the parotid 
and sublingual glands. When this condition exists there 
is danger of the sudden development of oedema giottidis, for 
the occurrence of which you should be on the watch. Du- 
ring the year that I had charge of the Small-pox Hospital, 
there were three cases in the hospital of oedema giottidis ; 
one case terminated fatally before I reached the patient ; 
life was saved in the other two cases by the performance of 
laryngotomy. 

In confluent small-pox the severity of the constitutional 
symptoms corresponds to the severity of the local manifes- 



282 SMALL-POX. • 

tations. The temperature during the initial fever often 
reaches 106° F. or 107° F., and in very severe types of the 
disease it may rise as high as 110° F. The pulse is corre- 
spondingly frequent and feeble. After the appearance of the 
eruption the temperature falls slowly to 103° F. or 104° F., 
where it remains until the stage of suppuration is reached ; 
then it again rises, in some cases even higher than during 
the period of invasion. Violent delirium is very frequently 
present during the fever of invasion, as well as during the 
period of secondary fever, and not infrequently patients 
pass, quite suddenly, into a state of coma. Uncontrollable 
vomiting and obstinate diarrhoea are not infrequent, coming 
on during the fever of invasion and continuing throughout 
the course of the disease. In all severe cases typhoid 
symptoms manifest themselves soon after the appearance of 
the eruption, and patients often lie for days in a semi-con- 
scious state, with dry, brown tongue, subsaltus, a low 
muttering delirium, and all the attendant phenomena of 
intense nervous depression. In all severe cases albumen 
appears temporarily in the urine. 

Complications occur much more frequently in confluent 
than in discrete small-pox. Inflammations of the serous 
membranes, especially pleurisy and pericarditis, are the 
most common. Croupous and catarrhal pneumonia fre- 
quently complicate the severe bronchial inflammation from 
which so few patients with confluent small-pox escape. 

Variola Hemorrhagica. — There is another form of 
small-pox which can hardly be regarded as a distinct variety, 
but rather as a modification of those varieties which have 
just engaged our attention, and which has been called hem- 
orrhagic variola. It differs from the varieties already de- 
scribed, not in the manner of its development as far as the 
initial fever is concerned, but in the appearance of the 
eruption. This hemorrhagic tendency is often manifested 
as early as the first appearance of the eruption, by the dark 
color which the eruption assumes. Sometimes the papules 
become hemorrhagic from the very moment of their devel- 
opment ; at other times they first become vesicles, and then 
become hemorrhagic. Again, at other times, the hemor- 



DIFFERENTIAL DIAGNOSIS. 283 

rhage first shows itself after the vesicles become pustules. 
In some cases the eruption over the whole body becomes 
hemorrhagic ; in other cases it is hemorrhagic in spots. 
In the majority of the cases of this variety, however, the 
eruption becomes hemorrhagic as soon as the papules have 
attained the size of a lentil, and the hemorrhagic change 
comes on slowly, generally commencing upon the lower ex- 
tremities. Petechise and ecchymoses usually appear be- 
tween the points of eruption, if the small-pox is of the 
discrete variety. 

In connection with the hemorrhagic eruption, at the same 
time you will have hemorrhages from the various mucous 
membranes of the body — from the mucous membrane of 
the nose, perhaps from the bronchial mucous membrane, 
and sometimes large ecchymotic spots may be seen upon 
the mucous surfaces of the mouth and throat. 

It is rare for this form of small-pox to reach the stage of 
suppuration, for before this stage is reached patients with 
hemorrhagic small-pox sink and die, either from the over- 
whelming influence of the small-pox poison, or from the ex- 
haustion caused by extensive hemorrhage. 

In females profuse menorrhagias are of frequent occur- 
rence, and often are so extensive as to endanger life. 

During the initial stage of this variety of small-pox, the 
constitutional symptoms do not differ from those which 
attend the development of the other forms of this disease. 
It is impossible, from their character and intensity, to pre- 
dict, with any degree of certainty, the subsequent develop- 
ment of hemorrhagic variola. It has been said that the 
pains in the back and limbs are more severe ; but these are 
not sufficient to characterize this type of the disease. Fre- 
quently the fever of invasion is exceedingly violent, while 
during the eruptive period, and during the entire subse- 
quent course of the disease, the temperature is compara- 
tively low ; sometimes during the entire course it does not 
rise above 102° F. In striking contrast with the low tem- 
perature is the frequency of the pulse. In those cases in 
vchich extensive hemorrhages have occurred, the tempera- 
ture often falls below the normal standard, while the pulse 



284 SMALL-POX. 

ranges from 140 to 160, and is exceedingly feeble in charac- 
ter. Only when a comparatively few of the vesicles be- 
come hemorrhagic does the case terminate in recovery. 

Before describing the modifications of small-pox produced 
by inoculation and vaccination, I will complete the history 
of those varieties which have already engaged our attention. 

Differential Diagnosis. — The first question that comes 
to us under this head is, How early can small-pox be 
recognized ? One who has seen very many cases of the 
disease may be able to reach a diagnosis on the third day, 
that is the first day of the eruption, although at that time 
there is nothing characteristic about the eruption or the 
ushering-in symptoms. It is, however, better and safer to 
wait until the second or third day of the eruption before 
committing yourselves to a positive diagnosis, for there is 
little to be feared from infection until the vesicles are fully 
formed ; then you may be positive in regard to your 
diagnosis. 

The exanthematous fever which, in its early stages, and 
on account of its eruption, is most liable to be taken for 
small-pox, is measles. 

Usually the eruption of measles is so distinct and well 
defined that you will not mistake its true character ; but 
there are cases of measles in which the eruption presents an 
appearance closely resembling the first appearance of the 
eruption of small-pox. Such cases are not altogether infre- 
quent. A number of cases of measles came under my ob- 
servation while in the Small-pox Hospital that had been 
sent by physicians to the hospital as cases of small-pox. 

If you defer making a diagnosis until the vesicles are 
fully developed, you need make no mistake of this kind. 

In measles there is cofyza, a cough, sneezing, redness and 
suffusion of the eyes. These symptoms are not present in 
small-pox. 

In small-pox, when the stage of eruption is reached, the 
temperature falls ; while in measles, when the eruption 
appears, the temperature continues to rise. The range of 
temperature is higher in small-pox than in measles. In 
these respects the two diseases differ sufficiently to enable 



DIFFERENTIAL DIAGNOSIS. 285 

yon to make a differential diagnosis. Again, if yon wait 
nntil the vesicles become umbilicated, it will hardly be 
possible that yon should make a mistake in diagnosis. 

During the period of initial fever it is possible to mistake 
small-pox for typhus fever. In both diseases there may be 
delirium, pain in the head, vertigo, high temperature, and 
evidence of great disturbance of the nervous system. I 
know of no symptom which will enable yon to make a 
positive diagnosis during the very early period of the dis- 
ease. Of course, if typhus fever is prevailing, or if small- 
pox is prevailing, and the patient has been exposed to 
either one of these contagions, you will be able to make 
a diagnosis without much difficulty. Usually there is 
greater loss of muscular power in typhus fever than in 
small-pox, but this symptom is not always well marked. 
By the third day, the appearance of the eruption upon the 
face, where it is first seen, settles the question of diagnosis. 
The eruption of typhus fever is first seen upon the abdo- 
men, and it may extend over the whole body without 
appearing on the face. It rarely appears before the fifth 
day of the fever. If, therefore, you wait until the eruption 
appears, the differential diagnosis between small-pox and 
typhus fever can be readily made. 

Meningitis is another disease which small-pox, in its 
initial stage, resembles. I have seen a case of small-pox 
treated for several days as a case of meningitis. There is 
always considerable cerebral disturbance, and a full, hard, 
bounding pulse in the initial stage of small-pox. Photopho- 
bia and intense pain in the head, as also nausea and vomit- 
ing, may be present in both diseases. Unless it may be the 
expression of the face, there is often no distinguishing 
mark between the two diseases in their early stages. In 
meningitis there is usually a pale, anxious expression of 
countenance, whereas early in small-pox the face is flushed, 
and day by day the flush deepens until the eruption appears. 
There is often a uniform redness over the entire surface of 
the body in confluent small-pox when the eruption appears, 
or at least that portion of it where the eruption makes its 
appearance. 



288 SMALL-POX. 

On the appearance of the eruption the differential diag- 
nosis between these two diseases is readily made. I wish 
to impress you with the fact that it is much better to wait 
in all doubtful cases, perhaps in every case of small-pox, 
until the eruption appears before attempting to make a 
diagnosis. 

It is an unfortunate occurrence whenever a patient, who 
is not sick with small -pox, is sent to a small-pox hospital, 
and it is equally unfortunate whenever a small-pox patient 
is retained in a family or neighborhood a sufficient length 
of time to expose the remaining members of his own family 
or other families in the neighborhood to the contagion of 
this disease ; but there is little danger of infection until the 
vesicles are fully formed. 

Prognosis. — The prognosis in any case of small-pox de- 
pends upon the amount of the eruption ; the more abun- 
dant the eruption, the greater the danger to life. The prog- 
nosis also depends upon the type of the disease. Unless 
some complication arises, the majority of cases of discrete 
small-pox recover ; while of confluent small-pox, which is a 
much graver disease, nearly one-half the cases prove fatal. 

The best record obtained in the Small-pox Hospital on 
the island was one death in every five cases. In the hemor- 
rhagic variety, whether discrete or confluent, a fatal termi- 
nation is almost inevitable. Only a very few cases of the 
hemorrhagic variety recover, and when recovery does take 
place it is only reached after the patient has passed through 
an apparently fatal condition of coma. 

The ratio of mortality is always lower at the end than at 
the beginning of an epidemic. It is more fatal in the sum- 
mer than in the winter. 

The age of the patient greatly influences the prognosis. 
In infancy and in extreme old age the ratio of mortality 
reaches its maximum. Among adults, the prognosis is 
worse in females than in males. In the intemperate the 
prognosis is always bad, for with this class of persons the 
disease is liable to assume a hemorrhagic type. The intem- 
perate die in discrete small-pox when the temperate will 
with almost certainty recover. In the overworked and 



PEOGT^OSIS. 287 

badly-nourished the prognosis is bad. Robust and healthy 
persons pass through a severe type of the disease much 
more safely than those enfeebled by syphilis and other 
chronic forms of the disease. 

The severity of the fever of invasion is not a safe guide 
in prognosis. Sometimes a severe initial stage precedes a 
mild form of the disease ; sometimes patients with this dis- 
ease pass into a state of complete unconsciousness, remain 
in that condition for some time, then the eruption begins to 
change in color, and finally recovery takes place. Such 
cases, however, are exceptional. 

However well developed the eruption may be, or however 
well filled the vesicles, you must remember that the eighth 
day is the commencement of the suppurative fever, which 
is the period of the greatest danger. Upon this day you may 
find your patient passing into a state of collapse, the result of 
the depressing influence upon the nervous system produced 
by the large extent of surface involved in the suppura- 
tive process. If patients do not die until the second week 
of the disease in most cases the fatal result is due to 
exhaustion, although death may occur from complications. 
Usually they pass into a typhoid condition, the result of 
the excessive drain upon the system while the suppurative 
process is going on. Secondary syphilis is occasionally 
developed during the period of desiccation. All such 
cases that have come under my observation have proved 
fatal. The most frequent complications which cause death 
are those which occur in the throat and air-passages. 
In some instances swelling of the glands of the neck and 
mucous membrane of the throat takes place to such an ex- 
tent as to seriously interfere with deglutition and respiration. 
When this occurs it becomes a great element of danger, and 
materially affects your prognosis. The tongue may become 
swollen to such an extent that the patient will be unable to 
protrude it, or, being able to protrude it, will not be able to 
retract it. Under such circumstances deglutition is almost 
impossible, and, as I have already stated, oedema glottidis is 
liable to occur. You may have laryngeal ulcers, and ulcers 
occurring in the trachea and in the bronchial tubes. These 



288 SMALL-POX. 

may give rise to changes which will so interfere with respi- 
ration as to cause the death of the patient. Death may 
also occur from general bronchitis or pneumonia. Perhaps 
the most dangerous complication is acute fatty degenera- 
tion of the kidney. Whenever, in the course of the disease, 
the urine becomes scanty and high-colored, but especialy 
when it becomes so at the commencement of the secondary 
fever, you may then be certain that you have kidney com- 
plication. Under these circumstances your patient may 
pass into a condition in which convulsions will be devel- 
oped, and coma and death ensue. 

Before leaving this subject I will call your attention to a 
case of confluent small-pox which came under my observa- 
tion about one month ago. I make mention of this case 
that I may impress upon you the importance of one symp- 
tom as regards prognosis, that is, the abundance of the 
eruption. 

I was called in to visit a gentleman who was in the initial 
stage of the disease. I had charge of him up to the third 
day of his illness. At that time an abundant small-pox 
eruption had made its appearance. He then passed into the 
hands of a younger physician, who seemed amazed when I 
said to him that I thought the patient would die. A few 
days later the physician informed me that the patient was 
doing well, and he thought I had made haste in my progno- 
sis. In reply I said, " wait until the ninth day." Upon the 
eiglitli day I saw my professional brother again. He then re- 
marked that the patient was very much worse, and he was 
afraid he was going to die. He died a short time after our 
last conversation. Now, the only symptom which led me so 
early to make an unfavorable prognosis was the abundance 
of the eruption. 

In the hemorrhagic variety of small-pox usually the stage 
of suppuration is not reached —the patient dies before that 
period on account of the extensive changes which take 
place in the blood. Under such circumstances you are lia- 
ble to have complete suppression of the urine, or, at least, 
sufficiently complete to give rise to uraemia in addition to 
the small-pox poisoning. 



TREATMENT. 289 

Treatment. — We now come to the treatment of small- 
pox. The first question that arises under this head is, 
have we any means by which we can arrest its development 
after the initial fever has been established ? In vaccination, 
properly performed, we undoubtedly possess a means by 
which we may prevent one from contraction of the disease 
when exposed to its infection. 

But the question now arises, have we any power to arrest 
the development or mitigate the severity of the disease after 
the initial fever is established ? No reliable affirmative an- 
swer has been given to this question. It has been proposed 
to accomplish this by blood-letting, emetics, diaphoretics, 
purgatives, cold-baths, and more recently by the subcutane- 
ous injection of the vaccine-virus.. All of these means have 
been tested and have failed to accomplish the desired result. 

The assertion that large doses of quinine, given during 
the stage of invasion, will shorten the duration and modify 
the course of the disease is verified only by the experience 
of its author. 

Quite recently, it has been claimed that carbolic and sali- 
cylic acid will destroy the septic poison of variola, and thus 
shorten and modify its course. My own experience as re- 
gards their use has not been sufficient to decide the ques- 
tion for myself, but I am unable to find any statistics which 
sustain such an assertion. 

During the fever of invasion all that you can do is to 
treat special symptoms. 

Place the patient in bed in a large, well-ventilated apart- 
ment ; if possible keep the temperature of the room below 
60° F. I remember that, in the Smalhpox Hospital, those 
patients did best who were placed in barracks which were 
so open, that frequently, during the winter months, when I 
made my morning visit, I would find little snow-drifts on 
the floor between the beds. 

When the body temperature ranges as high as 107° F. or 
108° F., it may be necessary to employ cold to the surface, 
and to give antipyretic doses of quinine to reduce the tem- 
perature. If the headache is severe and the face flushed, 
iced compresses and ice-bags to the head will usually afford 
19 



290 SMALL-POX. 

relief. If the vomiting is severe and constant, iced carbonic 
acid water, may be given, and if the vomiting is attended 
by great restlessness, hypodermic injections of morphine 
are indicated. Administer such food as can be readily as- 
similated. I have found nothing better than iced milk and 
seltzer water. If the bowels are constipated it is well to 
relieve them by enemas of cold water. 

In those cases in which the eruption is tardy in making 
its appearance, and the temperature is higher, sometimes, if 
the patient is kept in a warm bath for fifteen or twenty 
minutes, the development of the eruption is hastened. 

When the eruption has appeared, the measures to be em- 
ployed will vary with the character of the eruption. The 
milder forms of discrete variola require no interference. In 
the severer forms the attendant symptoms will decide the 
means to be employed. 

Sooner or later, sometimes ver}^ early in the severer- forms 
of the disease, you will find your patient sinking from the 
depressing effects either of the small-pox poison or of the 
suppurative process which is taking place upon the surface 
of the body. Under such circumstances you will be com- 
pelled to resort to the use of stimulants. There is no ques- 
tion but that the free use of stimulants for a few days, just 
at the period of suppuration, in very many cases does much 
to save life. At this time you may find your patient with 
a dry tongue, a frequent, feeble pulse, blue lips and linger 
ends, giving evidence that he is rapidly passing into a state 
resembling that met with in the latter stages of typhoid 
fever. Active delirium is frequently present ; the patient 
insists upon getting out of bed. Under these circumstances, 
the life of your patient will often be saved by the judicious 
use of stimulants. If the delirium is excessive, hypodermics 
of morphine may be combined with the administration of 
stimulants. During the stage of desiccation, warm baths 
employed every day, or every other day, give great comfort, 
and assist in the falling of the crust. After the baths, the 
surface should be freely oiled. 

Complications will be treated according to the general 
rules which govern their treatment. If abscesses occur 



TKEATMENT. 291 

in the subcutaneous tissue, they should early be freely 
opened. 

We are powerless when we come to deal with the hemor- 
rhagic form of small-pox. Although tonics and stimulants 
have been highly recommended, they do little good. Trans- 
fusion has been proposed and practised with no definite 
results. If the mouth and pharynx are very much involved, 
and there is difficulty in deglutition, ice-cold carbonated 
water with a weak solution of mur. tinct. ferri used as a 
gargle will often give great relief. Sometimes the stronger 
antiseptic gargles, such as carbolic acid and permanganate 
of potash, will be of service. 

There is still one point in the treatment of small-pox 
which is deserving of attention, and that is, what means 
may be employed to prevent the pitting, especially upon 
the face, which is so frequent an accompaniment or the re- 
sult of small-pox \ As I have already stated, the eruption 
first makes its appearance upon the face ; there it is usually 
most abundant, and is most liable to be followed by pitting, 
and there it passes more quickly through all its stages than 
upon any other part of the body. In order to prevent the 
pitting, it has been proposed by some to exclude light and 
air from the surface covered by the eruption. For this pur- 
pose a great many substances have been employed, such 
as collodion, gutta-percha, certain forms of plaster, liquid 
paper, etc., etc. All these substances are to be so applied 
as to form a mask for the face, which should completely 
exclude light and air from the surface. 

You will recollect that I stated that the pitting was due 
to the formation of a slough, and that the slough was seated 
in the areolar tissue, and that if by any means you can so 
interfere with the inflammatory process as to prevent the 
formation of a slough, you will prevent the pitting. It was 
claimed by those who advanced the theory, that excluding 
light and air prevented pitting ; that it did this by prevent- 
ing the occurrence of sloughing. 

At the time when I had charge of so many small-pox pa- 
tients, I took pains to test all those applications, which at 
that time had been and are still recommended for that pur- 



292 SMALL-POX. . 

pose, and I satisfied myself that about the same results were 
obtained in the use of every remedy, and in no case was pit- 
ting prevented. Certain patients were much more scarred 
than others, but that was the natural result of the disease. 
Some have proposed to coagulate the serum in each 
vesicle by means of iodine or nitrate of silver, and so arrest 
the inflammatory process and prevent pitting. But the use 
of these means has been attended by the same unsatisfactory 
results. The only means which I found of certain value 
was simple cold-water dressing applied over the face, after 
having ruptured each vesicle before it became a pustule. 
In this way, I was able to diminish the intensity and extent 
of the inflammation. This plan of treatment I adopted in 
twenty cases of confluent small-pox, and it not only gave 
the patients very great comfort, relieving them to a certain 
extent from the intense itching, thus avoiding rupture of the 
vesicles by scratching, but in not a single case that recovered 
was there bad pitting. In the treatment of small-pox, the 
prevention of pitting is of greatest importance to a certain 
class of patients, especially young unmarried females. 



LECTURE XXV 



SMALL-POX 



Treatment (continued). — Inoculation. — Vaccination. — 

Varioloid. 

We will now consider the two recognized methods for 
rendering small-pox poison so innoxious that, when one has 
been exposed to its influence, he will be perfectly safe from 
infection. These two methods are known as inoculation 
and vaccination. 

Inoculation was first introduced into England in the year 
1781, by Lady Montague, who first practised it upon her 
own child, she having become familiar with the practice 
while travelling in Italy, where the practice undoubtedly 
originated. Subsequently it was quite generally practised 
throughout Great Britain. Pus from a small-pox pustule 
was introduced beneath the epidermis of one who had been 
prepared, by diet and general hygienic measures, for the 
safe development of the disease. It was claimed that the 
disease resulting from inoculation was a modified small- 
pox, differing from the original disease in that it ran its 
course more rapidly, was attended by the formation of a 
fewer number of pustules — perhaps no more than twenty 
or thirty upon the entire body— and was said to rarely 
terminate fatally, the ratio of mortality being about one in 
one hundred. The patient who had the disease in this 
.manner was equally protected with those who had the 
disease in the ordinary manner, being exempt from a 
second attack. 



294 SMALL-POX. 

The disease developed by inoculation passed through the 
regular stages of a case of ordinary small-pox — that is, 
there was the initial fever, the eruption, and the desicca- 
tion, one stage following another in regular succession. 
This procedure was found more or less unsatisfactory, for 
it had its disadvantages ; there was danger in it, and inocu- 
lated persons could communicate small-pox to others. 

During the latter part of the last century, Sir William 
Jenner observed that, in some of the northern counties of 
England, persons employed in dairies, who suffered from a 
certain form of ulcer upon the hands, did not contract 
small-pox when exposed to the influence of its poison. He 
also found that these ulcers found upon the hands resem- 
bled pustules found upon the udder of the cow, and seemed 
to have been caused by contact with them. Jenner made 
a thorough investigation of the subject, and arrived at con- 
clusions sufficiently satisfactory to himself to warrant the 
experiment of taking matter from one of these pustules 
found upon the udder of the cow and introducing it into 
the arm of an individual who was supposed to be unpro- 
tected from the contagion of small-pox. After the sore 
upon the arm had run its course, he exposed the individual 
to the infection of small-pox, and in this way he estab- 
lished its protecting power. 

His first experiment was made in the year 1791 ; but it 
was not until six years afterwards that the experiment was 
repeated by any other person. During these six years it 
is probable that no member of the profession ever received 
more anathemas or more scurrilous abuse than did Jenner. 
He was attacked by the leading physicians and surgeons 
of Great Britain, and persecution and ridicule so followed 
him, that placards with caricatures of Jenner were posted 
throughout the streets of London and the principal towns 
of Great Britain. 

Jenner kept steadily at work and repeated his experi- 
ments, until he became fully convinced that by vaccination 
perfect protection could be obtained against small-pox. 
Within the short space of six years Jenner compelled the 
profession to admit his statements and adopt his practice, 



VACCINATION. 295 

and, within the five or six years following its first recog- 
nition, the practice of vaccination became nniformly recog- 
nized and practised. 

Vaccination was introduced into this country in the year 
1802, by two Boston physicians, and it very soon became 
the practice of the entire profession. At the present time 
there is no question among the intelligent portion of the 
profession, but that vaccination, properly performed, is a 
perfect protection against the infection of small-pox ; if 
persons contract small -pox after they have been vaccinated 
you may infer it has not been properly performed. We 
have no other means of protection. 

We will now study the subject of vaccination. There 
are two methods of performing it. One method is to take 
the virus directly from the cow, this is called bovine virus ; 
the other method is to take the virus from a vesicle de- 
veloped upon the human body, perhaps a vesicle removed 
from the original by several vaccinations, this is called 
humanized virus. It has been a common practice to use 
virus taken from a vesicle that was removed from the 
original vesicle by two, Hve, ten, twenty or even forty 
vaccinations, on the supposition that just as perfect pro- 
tection was afforded as though the vaccine was taken 
directly from the cow. 

Within a few years it has been found that such a large 
proportion of the population were not protected from the 
infection of small-pox, and that cases of small-pox were so 
markedly increasing in number, that a return has been 
made to the bovine virus. To-day, this form of virus is 
used by a majority of the profession. I use it because 
when I obtain a perfect vesicle, after its introduction into 
the system I am convinced that the person is thoroughly 
protected against the infection of small-pox poison. I never 
have this assurance when I use the humanized virus. 

Dr. Jenner found that there were several pustules de- 
veloped on the udder of the cow, which closely resembled each 
other, but that only one contained the virus which afforded 
protection from small-pox. In obtaining bovine virus it is 
of the greatest importance that the genuine vesicle be 



296 SMALL-POX. 

selected. In order to make the selection it is necessary one 
should be familiar with the peculiarities of each variety. 

Dr. F. B. Foster and Dr. E. H. Pardee, of this city, have 
given this subject much study, and their experience and 
facilities enable them to furnish bovine virus which is per- 
fectly reliable. 

If humanized virus is used, not only is the protection less 
certain and less permanent, but there is danger of intro- 
ducing into the system the infection of other diseases. I 
have in my possession facts which prove beyond the possi- 
bility of a doubt that syphilis can be conveyed from one 
person to another by vaccination. In two instances, which 
came under my own observation, it was so conveyed when 
the humanized vaccine Lymph was employed. 

Cutaneous eruptions may also be conveyed by humanized 
vaccine virus, which may cause the development of very ex- 
tensive and serious cutaneous diseases. 

Again, it must be remembered that if any chronic or 
acute skin disease exists at the time the vaccine vesicle is 
running its course, the protective power of the vaccination 
will be altogether destroyed or very greatly modified. 

In obtaining vaccine virus for use, both the bovine and 
the humanized virus should be taken from the vesicle on the 
eighth day. The lymph should be taken from the vesicle 
before the inflammatory process has commenced which is to 
change it into a pustule. A few years ago it was the common 
practice in this city to use the vaccine crusts, but this prac- 
tice has fallen almost entirely into disuse because of the 
great danger of transmitting disease from one individual to 
another. 

Always use the bovine virus when it is possible to obtain 
it. If compelled to use the humanized virus, use the lymph. 
You must puncture the vesicle in such a manner that the 
lymph cannot be contaminated by the blood ; this is best 
done by introducing your instrument parallel with the arm. 
The lymph which flows from such a puncture can be pre- 
served upon the convex surface of a piece of quill, and con- 
veyed from one individual to another. Vaccine virus se- 
cured from the human arm in this manner is less liable 



VACCINATION. 297 

than any other form of humanized virus to do permanent 
harm to the vaccinated individual. 

The vaccine virus is usually introduced by scarifying the 
surface, so as to redden it, scarcely drawing blood ; then 
the surface of the quill containing the virus is applied to 
the scarified part, or the lymph is conveyed from one to the 
other by direct transmission. The operation is simple, and 
one with which you are doubtless familiar. It is not neces- 
sary for me to say anything in regard to the manner of 
performing it. 

Any irregularity in the development of the vesicle de- 
stroys in a greater or less degree its protecting power. 

When an individual has been previously vaccinated, it is 
liable to run an irregular course. A primary vaccination, 
such as the first vaccination of a child, should pass througli 
the following regular stages ; if it does not, it fails in its 
protecting power : Upon the third day after the introduc- 
tion of the virus you will notice at the point where it was 
introduced a little red spot. By the fourth day this little 
red spot will be occupied by a vesicle, and at the commence- 
ment of the fifth day you will begin to see around the 
vesicle a little yellow margin. Now you have a vesicle with 
a yellowish- white margin at its base. This vesicle goes on 
increasing in size up to the eighth day, when you will 
notice that it has become umbilicated, and that there is 
around it a distinct areola. Previously there has been a 
trilling areola present ; now it becomes very distinct. The 
vesicle is free from inflammation, and now is the time to 
take the lymph for the purpose of vaccination, for the 
vesicle is complete. The lymph should be taken only a 
short time before using it. JSTow a change is to take place 
in the vesicle, and by the next day you will notice that the 
areola has extended, perhaps so as to measure an inch in 
diameter ; this areola goes on extending itself through the 
ninth, tenth, and eleventh days, when it will have reached 
its maximum extent, which may be one or two inches from 
the vesicle in all directions. It is now of a deep red color. 
The part over which the areola has spread is more or less 
elevated, the arm is considerably swollen and painful, and 



298 SMALL-POX, 

the adjacent glands more or less enlarged, and tender to 
the touch. The extent of the enlargement of the gland 
adjacent to the vaccine vesicle, the axillary gland, if the 
vesicle is upon the arm, the inguinal, if it is upon the 
thigh, varies considerably in different persons. In some it 
is very great, in others it is scarcely noticeable. 

The maximum degree of inflammation in the vesicle has 
now been attained, and there is a distinct infiltration of the 
tissue about it. On the twelfth or thirteenth day, the red 
areola begins to decline, the swelling diminishes, and the 
vesicle, or, more properly speaking, the pustule, ruptures, 
and the contents escape. The rupture belongs to the 
natural course of the vaccine vesicle, and is independent of 
mechanical violence. From this time the inflamed areola 
becomes less and less distinct, and by the fourteenth or fif- 
teenth day the crust has assumed a dark, brownish appear- 
ance, which goes on deepening, until you find on the 
seventeenth day a deep-brown crust having a central de- 
pression and no areola of inflammation. It maybe attached 
to the surface only in one or two places, and can be readily 
removed ; if permitted to remain, usually it falls off on the 
eighteenth day. This is the course pursued by a perfect 
vaccine vesicle. The shape and size of the crust will cor- 
respond to the shape and size of the vesicle, and in this way 
you will be able to determine whether the vesicle has or has 
not pursued a regular course. Of course, the crust will 
vary in shape according to the vaccination ; if you make 
an irregular scarification, you may expect an irregular 
crust, for you will have an irregular vesicle. If the virus 
is introduced at a single point, the vesicle will be circular, 
and the crust that is formed will also be circular, and oc- 
cupy the exact space occupied by the vesicle ; if otherwise, 
it is evident that the regular course of the vesicle has been 
disturbed. 

So, also, if upon the eighth day you find a pustule instead 
of a vesicle, you may be certain that the regular course of 
development of the vesicle has been disturbed, and complete 
protection is not afforded against the infection of small-pox. 

The inflammatory process around the vesicle is usually 



VACCINATION. 299 

more active when the bovine virus is used, than when the 
humanized virus is introduced, and there is more constitu- 
tional disturbance. Ordinarily, during the development of 
the vaccine vesicle and pustule, there is but little constitu- 
tional disturbance ; this is usually self -limiting, and not 
sufficiently severe to require treatment. About the eighth 
or ninth day, the person vaccinated may feel a little chilly, 
and have severe headache ; in most cases there is a slight 
rise in temperature. 

The regular course of the vaccine vesicle maybe inter 
fered with by the occurrence of an erysipelatous inflamma- 
tion, and if such an inflammation does occur during the 
course of its development, it entirely destroys the pro- 
tecting power of the vaccination. 

Again, if a large quantity of pus has been discharged, 
and healing of the ulcer does not take place for two or three 
months, it is evident that something besides genuine vaccine 
virus has been introduced into the arm. In other words, 
such a vaccination has not pursued a regular course and is 
not protective. As I have already stated, the presence of a 
vesicular eruption upon the surface at the time vaccination 
is performed will interfere with its development, therefore 
I would advise you never to vaccinate one who has an ec- 
zematous eruption upon any part of the body, unless he 
has been exposed to the contagion of small-pox, for it is 
very probable that the vaccination will not be a protective 
one. 

It is better never to vaccinate a person having any form 
of skin disease, especially if the eruption is vesicular in 
character. The best time for the performance of vaccination 
is in infancy, between the third and fifth months. 

Revaccination should be performed after puberty, and 
always after or preceding a new exposure to the contagion 
of small-pox, for the period during which revaccination 
will afford complete protection is not the same in each in- 
dividual. In some cases a single vaccination will afford 
complete protection for a lifetime. In other cases it is 
necessary to frequently repeat the vaccination, perhaps 
every two years, in order to secure the desired protection. 



300 SMALL-POX. 

Not unfrequently persons are astonished when the re- 
vaccination runs a regular course, for they suppose them- 
selves perfectly protected against the contagion of small- 
pox. 

The question has been raised, If vaccination be performed 
previous to an attack from any severe disease, will not the 
protecting power of the vaccination be destroyed by that 
disease ? Certain facts seem to indicate that such is the case. 

Again, is it necessary to repeat vaccination in order to 
secure its protecting power? To explain my meaning. 
There is no question but that a child may be repeatedly 
vaccinated, and after each vaccination may have some sort of 
a local manifestation, but he will never have but one perfect 
vaccine vesicle. If the primary vaccination runs a regular 
course, it affords protection, and the second introduction of 
the virus seems to me to be unnecessary, as it simply de- 
velops an irregular vaccine vesicle. Nor does the introduc- 
tion of the virus at two places at the same time seem to be 
necessary, for one perfect vesicle is sufficient. 

The next question which presents itself is, What kind of 
disease is that which is developed in individuals who are 
protected by vaccination, when they are exposed to the in- 
fection of small-pox ? 

Unquestionably it is a modified form of small-pox. It 
has received the name of varioloid. 

Varioloid. — This is a disease — the result of an exposure 
to the contagion of small-pox — which would be small-pox, 
had the person exposed to this contagion never been vac- 
cinated. During every epidemic of small-pox you will meet 
with a certain number of cases, concerning which you will 
be in doubt whether to call them cases of variola or vario- 
loid. Certain persons who have never been vaccinated, on 
account of their naturally slight susceptibility to the infec- 
tion of small-pox, may have such a mild form of variola 
that it is difficult to distinguish it from varioloid. 

There are certain points of resemblance between varioloid 
and variola, and there are certain marked differences. Va- 
rioloid differs from small-pox in the rapid development and 
decline of the eruption, in the small number of the pustules, 



VAEIOLOID. 301 

and in the short time required for the formation and sepa- 
ration of the crusts. The entire period of the eruptive 
stage often does not last more than a week. Rarely are 
there cicatrices or pits after the disappearance of the erup- 
tion. 

In varioloid and variola the pustules pass through simi- 
lar stages. We first have the small red spot, then vesicles 
form, often within twelve hoars after the appearance of the 
eruption. These vesicles rapidly increase in size ; sometimes 
they are umbilicated ; by the end of the third day their 
contents sometimes becomes purulent, without any tume- 
faction of the surrounding skin. On the fifth day desicca- 
tion commences, and is often completed by the seventh day. 
The majority of the pustules simply dry up, without pre- 
viously bursting, forming brown crusts which are thinner 
and smaller than those of variola. 

In varioloid you rarely have the regular period of devel- 
opment such as you have in variola. In variola there is the 
period of eruption, during which the vesicle is perfected ; 
this is succeeded by the period of suppuration, then by 
desiccation, about fourteen days being required to complete 
the process ; while in varioloid the course of the eruption 
is irregular, and is usually completed within one week. 

Again, in varioloid there is but little constitutional dis- 
turbance after the appearance of the eruption. It resem- 
bles variola in the severity of the symptoms during the 
period of invasion, during which time you will not be able 
to determine whether the case is one of varioloid or one of 
small-pox. If you are watching, lest small-pox may be 
developed, then you may be led to suspect its advent from 
the severe pain in the head and back, and from the general 
febrile disturbance following an exposure to the infection 
of srnall-pox ; but as soon as the eruption appears there is 
an entire cessation of all the active febrile symptoms. Dur- 
ing the period of invasion varioloid may be said to very 
closely resemble variola. 

When an individual is exposed to varioloid, the most 
severe case of confluent small-pox may be the result. This 
fact proves that varioloid is a modified form of small-pox 



302 SMALL-POX. . 

which has been produced by vaccination. It is now gener- 
ally conceded that varioloid is small-pox having a shorter 
duration and a milder course than usual. 

You may say we modify small-pox by inoculation. We 
do not. There is the same regular development of the dis- 
ease after inoculation that we have in the ordinary form of 
small-pox ; we only modify its intensity ; while by vaccina- 
tion we not only lessen the severity of the disease, but we 
are able to so modify the stages of its development as to 
shorten its duration. 

Prognosis. — Usually the prognosis is good. The diagno- 
sis is readily made. The rapidity with which the vesicles 
are developed, their shorter duration, the subsidence of the 
fever, and the appearance of the eruption, together with the 
usual duration of the attack, are sufficient to distinguish it 
from variola. 

Treatment. — The treatment for varioloid is the same as 
for a mild or modified form of small-pox. The patient 
should be placed in a large, well-ventilated room, quaran- 
tined the same as though suffering from variola. If the 
form of invasion is severe, saline cathartics may be admin- 
istered. When delirium is present, and the pain in the 
back is very severe, the moderate use of opium is admis- 
sible. 

As soon as the eruptive period of varioloid is reached no 
treatment is required; the patient passes on to a rapid and 
complete convalescence. 

Before leaving the subject of variola, I will refer to a few 
complications which do not belong to its natural history. 

As I have already stated, there really is no dividing line 
between the local affections of this disease and most of 
its complications. Bronchitis, more or less severe, accom- 
panies nearly all cases. In some it leads to catarrhal pneu- 
monia, the occurrence of which is always attended with 
danger. Pleurisy and pericarditis occasionally occur as 
serious complications. 

Laryngeal inflammations are a part of its history. When 
the laryngitis is accompanied by extensive ulceration of the 
laryngeal mucous membrane, or when acute oedema of the 



VAKIOLOID. 



303 



glottis is developed, or when it assumes a diphtheritic char- 
acter,, you have developed a series of complications which 
often quickly destroy life. 

Meningitis and cerebral complications are not of common 
occurrence in variola, although acute meningitis and oedema 
of the brain do sometimes occur ; so that when very active 
delirium or sudden coma come on during the eruptive 
stage of the disease there is reason to fear their develop- 
ment. 

A severe form of conjunctivitis may occur, which is some- 
times attended by the development of pustules on the pal 
pebral conjunctiva or upon the cornea. When they develop 
on the cornea, perforation, iritis, and suppuration of the 
globe may cause destruction of the eye. 

In hemorrhagic small-pox hemorrhages into the retina 
sometimes occur, causing sudden blindness. 

Suppurative otitis may occur and may be the cause of 
partial or complete deafness. 

Pyaemia is a very rare complication of variola, although 
during convalescence superficial cellulitis, terminating in 
abscess, is not infrequent. 

In severe cases, during convalescence, oedema of the feet, 
due to anaemia, is frequently met with, but I have never re- 
garded it as of serious import. 



LECTURE XXVI. 



SCARLET FEVER. 
Introduction. —Morbid Anatomy. — Etiology. — Symptoms. 

This morning we come to the study of the second in the 
list of exanthematous fevers, namely, scarlatina or scarlet 
fever. This name has been given on account of the bright 
red appearance of its eruption. 

Scarlet fever is an inflammation of the tegumentary in- 
investment of the entire body, both cutaneous and mucous, 
accompanied by a fever of an infectious or contagious char- 
acter. 

It is a disease of childhood, but may occur at any age. 

Its development and course is divided into periods : 
First, the period of invasion, which lasts from twenty -four 
to forty-eight hours ; then, the period of eruption, lasting 
from five to seven days ; afterwards, the period of desqua- 
mation, during which the entire epithelial surface is re- 
moved. 

Some authors have classified this disease according to its 
severity ; others according to the prominent organs of the 
body which are involved ; others according to the promi- 
nent phenomena which attend its development. 

The more common classification, and certainly the sim- 
plest, is that which divides it into scarlatina simplex, scar- 
latina anginosa, and scarlatina maligna. I shall adopt 
this last classification. 



MORBID ANATOMY. 305 

Scarlet fever has many different types ; these are as unlike 
as some of the distinct types of fever. 

Morbid Anatomy. — There are no characteristic anatomi- 
cal lesions of this disease, except those changes which have 
their seat in the skin and mucous membranes. I stated 
that the characteristic anatomical changes of variola were 
to be found in the eruption which followed regular stages 
of development, so in scarlet fever the eruption is the dis- 
tinguishing lesion. 

The eruption makes its appearance on the second or third 
day after the commencement of the febrile symptoms. 

At that time it consists of very numerous and closely 
aggregated points about the size of a pin's head ; between 
these the skin is of its natural color. In typical cases, 
these points are equally distributed over the entire body 
except the face. These red spots are usually circular in 
shape, slightly elevated above the surrounding skin, and so 
close to each other that they give a confluent redness to the 
entire surface. In mild cases the red points remain isolated, 
and do not become confluent ; as the eruption develops 
these red points unite. In severe cases the skin becomes 
turgid and swollen, and presents a uniformly red and glisten- 
ing appearance. In malignant cases the hypersemia of the 
skin is often accompanied by more or less extensive hemor- 
rhages, causing petechia and extensive ecchymosis. 

The eruption gradually increases in redness to a certain 
point, which is not the same in all cases, then remains un- 
changed for twelve or twenty -four hours, after which time 
the redness slowly passes away. During the course of the 
disease the color often changes with the exacerbations and 
remissions of the fever. As a rule, the degree of redness 
depends upon the intensity of the fever, and may vary from 
a pale red to a dark scarlet color. If the respiration be- 
comes impeded, the eruption assumes a bluish-red hue. 
During the first forty-eight hours after the appearance of 
the eruption, when the respiration is unimpeded, the red- 
ness completely disappears under firm pressure, and reap- 
pears as soon as the pressure is removed. After this period, 
the pressed point does not entirely lose its red color. 
20 



306 SCAELET FEVEE. 

In a certain proportion of cases, the eruption only ap- 
pears in spots on the surface of the body, on the trunk, 
or face, or about the flexors of the joints. When it only 
appears on the face the diagnosis is difficult. In addition 
to the cutaneous hyperemia which gives the redness to the 
surface, there is more or less serous exudation into the 
u rete Malpighii," which is followed on the decline of the 
redness of the surface by an abundant epidermic exfolia- 
tion. This exfoliation marks the period of desquamation, 
which may immediately follow the decline of the redness 
or it may be delayed a few days. This is due to an exces- 
sive production of newly-formed epidermis, and the process 
may last only a few days, or if the eruption is abundant it 
may continue for several weeks, and may recur a second 
time on the same surface. After the desquamation has 
ceased, it does not reappear, except in cases of relapse; 
these are followed by renewed and sometimes by a very 
complete desquamation. 

In connection with these cutaneous changes the scarlatina 
poison causes changes in the mucous membrane of the 
mouth and throat, the most frequent of which is catarrhal 
pharyngitis, which at first gives to the mucous surfaces of 
the tonsils and pharynx a red, swollen, and dry appear- 
ance. After a little time, these mucous surfaces become 
covered with a tenacious mucus. Upon the reddened mu- 
cous membrane, small elevations arise, like the smaller 
follicles in an ordinary catarrh. In mild cases, all these 
changes disappear in a few days ; in the severer cases, the 
mucous surface assumes a dark, livid color, the parts become 
more or less cedematous, and are covered by an abundant 
secretion. The oedema may be so extensive as to render 
deglutition difficult ; often the tonsils are so swollen that 
they touch each other. Besides the redness and oedema of 
the mucous membrane of the mouth and throat, there is 
often inflammation of the parotid and sublingual glands 
as well as of the connective tissue of the neck. This gland- 
ular inflammation may end in resolution, but often it termi- 
nates in suppurative or diffused necrosis. It may give rise 
to extensive gangrene of the tonsils and adjacent soft parts ; 



MORBID ANATOMY. 307 

some times it is followed by extensive abscesses and destruc- 
tion of the cellular tissue about the neck ; the skin in the 
region may slough, and not infrequently fatal hemorrhage 
may result from the destruction of small vessels. 

Diphtheria is so often a complication of scarlatina angi- 
nosa, that it has been assumed that there is some necessary 
relation between the two diseases. Yet diphtheria is as 
frequently met with in the mildest as in the severest types 
of scarlatina, and occurs in every stage of the disease ; often 
it is present during the period of incubation, so that the 
symptoms of the two diseases appear simultaneously. 
Again, it is met with during the period of convalescence. 
In some instances, scarlatina seems to complicate diph- 
theria. 

In a mild form of scarlet fever, when the disease runs a 
regular course, the nasal mucous membrane is usually pale, 
and its secretion is not increased. When the disease is 
severe, the nasal mucous membrane becomes secondarily, 
never primarily, involved. This is the result of a catarrhal 
affection of the throat. It is a purulent catarrh of the 
posterior nares, which gradually extends to the anterior 
nares, and gives rise to a very troublesome form of coryza. 

During the eruptive period of scarlatina, affections of the 
ear frequently occur in connection with those of the throat. 
Usually these have their seat in the middle ear. They are 
always tedious and may become chronic. 

Next to the skin and mucous surfaces, the kidneys are 
the organs most frequently affected in this disease. There 
is no question but that, in a certain proportion of cases, re- 
covery takes place without any kidney lesions ; but these 
are the exceptions and not the rule. The usual, and by far 
the mildest affection of the kidneys in scarlatina is a ca- 
tarrh of the uriniferous tubules marked by a more or less 
extensive epithelial desquamation. In some epidemics the 
scarlatina poison induces croupous inflammation of the 
uriniferous tubules instead of simple catarrh. 

The tubules of the cortical substance of the kidneys are 
most extensively affected ; the morbid processes commencing 
at the Malpighian tufts follow the course of the convoluted 



308 SCARLET FEVER, 

tubules. If the tubules are only slightly affected there 
will be no symptoms except a slight albuminuria. 

In well-marked scarlatinal nephritis, the epithelial cells of 
the uriniferous tubes will be found clouded, enlarged, and 
changed in shape and position, and frequently entirely 
destroyed, or they may entirely block up the tubules. 
Circumscribed inflammatory masses will be found scattered 
throughout the substance of the kidneys ; these cause the 
kidneys to present the appearance of interstitial nephritis. 
Sometimes abscesses form in the kidneys. These kidney 
changes are rarely well marked before the second or third 
week of the disease, and usually terminate in complete 
recovery ; they very rarely lead to chronic kidney disease. 

The character and extent of these kidney changes varies 
in different epidemics. During some epidemics, the kidney 
changes are slight ; during other epidemics almost every 
case, whether mild or severe, will be attended by extensive 
kidney lesions. 

At the post-mortem examination of scarlet fever patients, 
you will always find more or less extensive congestion of 
the internal organs, such as congestion of the brain, liver, 
spleen, etc., but these congestions do not vary in character 
from those met with in other acute infectious diseases. It 
has been said that the visceral lesions of this disease do not 
essentially differ from those of typhus fever, that there is 
the same tendency to softening of the spleen and liver, and 
that the condition of the cerebral vessels in the two diseases 
is very similar. In both, the changes in the constituents 
of the blood are such as to diminish its coagulating power ; 
in both, the mucous membrane of the stomach and intestines 
undergoes similar changes, the Peyerian patches will often 
be found presenting the " shaven-beard appearance." 

When scarlet fever poison, which usually only induces 
changes in the skin, throat, and kidneys, excites inflam- 
mation in the joints, pleura, and pericardium, these latter 
must be regarded as complications ; they do not belong to 
the regular history of the disease. 

Etiology. — The cause of scarlet fever is a peculiar sub- 
stance which is transferable from the sick to the healthy. 



ETIOLOG-T. 309 

Scarlet fever is unquestionably a contagious disease. It lias 
been claimed by some that it is only propagated by con- 
tagion ; by others that sporadic cases do occasionally occur; 
but there is little doubt, if the history of every case of sup- 
posed spontaneous scarlet fever could be carefully taken, it 
would be found that at no place and at no time had there 
ever occurred a case of spontaneous origin. 

The disease may be conveyed directly from the affected to 
the healthy by contact. It may also be conveyed for a few 
feet through the atmosphere, and also by clothing which 
has been thoroughly saturated with the scarlet fever poison ; 
therefore it may be considered a portable disease. 

Animals that have been around those sick with scarlet 
fever may convey it. I now recall one instance in which 
the scarlet fever poison was conveyed in this way. For a 
number of days a little poodle dog had been around children 
sick with scarlet fever, and in a single visit to the children 
of another family the disease was conveyed. 

There has been considerable discussion as to whether the 
disease can or cannot be conveyed in milk. I do not say 
that this is impossible, but I do not think it probable that 
it is so conveyed. 

The infection of scarlatina is not so certain as that of 
measles or small-pox. When one member of a family is 
sick with measles, usually every other member of that 
family who has not had measles will contract the disease ; 
whereas, one member of a family may be sick with scarlet 
fever and every other member may escape. 

I stated that some persons seem to have a certain idiosyn- 
crasy, so that when they are brought in contact with the 
typhus fever poison they do not contract the disease; so 
certain persons may be brought in contact with the poison 
of scarlet fever and yet not contract the disease. The 
poison which they receive into the system has power to pro- 
duce some of the symptoms, but has not power to fully 
develop the disease. 

Scarlet fever can be communicated from one individual to 
another by inoculation. If you take some of the watery 
material or serum that can be obtained from the minute 



310 SCAELET FEVER. . 

vesicles occasionally seen upon the surface of the body in 
connection with the scarlet fever eruption, and introduce it 
into the body of an individual who has not had scarlet fever, 
it will develop the disease. It has been proposed to inoculate 
persons who have not had scarlet fever in the same manner 
as one would inoculate persons who have not had small- 
pox, and, by so doing, produce a modification of the disease. 
But it has been found by experiment that those who have 
been inoculated for scarlet fever have suffered more severely 
than those who contracted the disease by any of the com- 
mon methods of contagion. 

There is no question but that the scarlet fever poison can 
also be introduced into the system through the respired air, 
but whether it can be taken into the system through the 
medium of food or fluids is still an unsettled question. 

We are now brought to a question of great practical 
importance. If the disease can be conveyed by clothing, is 
it safe for a physician to visit patients sick with scarlet 
fever, and go from them directly to those who have not had 
the disease % Unquestionably, it is possible to so convey the 
disease, but in my own experience I know of no case where 
it has been so conveyed. 

The clothing, in order to be sufficiently impregnated with 
the poison to render it a means of contagion, must be longer 
exposed than is the case when a physician makes a visit of 
ordinary length. 

I do not hesitate to go directly from a patient who has 
had scarlet fever to one who has never had the disease. 

While making my daily round of visits on scarlatina 
patients, I have frequently taken my own child, who has 
never had the disease, to ride with me, without fear of 
conveying to her the disease. 

Unquestionably, nurses who have been with a scarlet 
fever patient for a number of days, and whose clothing has 
become filled with the poison, may carry the disease. Such 
persons should change their clothing before they go from 
the sick to the healthy. 

With regard to the real nature of the scarlatina poison, 
the oft-repeated question comes to us, Is it a living organ- 



SYMPTOMS. 311 

ism or an impalpable poison % It is unnecessary to repeat 
what lias been already said upon this point. The same 
arguments hold good in regard to this fever as in regard to 
the other fevers which we have been considering. 

The period at which this disease is most infectious is 
probably the desquamative period, although some maintain 
that it is most infectious daring the eruptive period. An 
individual is almost certain never to have a second attack. 

The period of incubation varies from two to ten days, the 
average duration being from four to seven. 

Age has a great influence on individual predisposition. 
The greatest susceptibility to the influence of the poison 
exists between the second and seventh years ; it rapidly 
diminishes after the ninth year, so that adults, and espe- 
cially the aged, have only a slight predisposition to the 
infection. 

Scarlet fever may be endemic or epidemic. No reason 
can be assigned for the variations in type or severity of this 
disease. For years the type of fever which appears in a 
given locality will be exceedingly mild in character, and 
the cases will be mostly sporadic, when suddenly, without 
any assignable cause, a most malignant epidemic of the 
disease will prevail. Usually epidemics of scarlatina pre- 
vail in the autumn and spring. 

Symptoms. — The symptoms of scarlet fever vary with the 
type and with the severity of the fever. In moderately 
severe cases, before the appearance of the eruption, the 
patient will have more or less severe headache, pain in the 
back and limbs, and at first coldness of the surface. In 
some cases rigors will occur, and perhaps distinct chills. 
In children convulsions often occur. These ushering-in 
symptoms are immediately followed by a sensation of in- 
tense heat, with great acceleration of the pulse, which at 
this time often beats 120 or 130 per minute. There will also 
be nausea and vomiting, which symptoms are frequently the 
most persistent and distressing. Besides, there will be a 
rapid rise in temperature. It may reach 103° F. or 104° F., 
within a few hours. Within a period lasting from twelve 
to forty-eight hours, the average about thirty-six hours, 



312 SCAELET FEVER. 

the eruption makes its appearance, and the fever increases. 
The elevation in temperature is accompanied by restless- 
ness, a burning sensation, perhaps delirium ; the nausea 
and vomiting become more urgent, and now the papillse of 
the tongue become swollen, and the organ presents the 
appearance of a strawberry. It has been called the " straw- 
berry tongue" of scarlet fever. This appearance is not 
commonly seen in the milder cases, but, as a rule, is present 
in all the severer cases. With the appearance of the erup- 
tion, all the symptoms, perhaps excepting the pain in the 
head, increase in severit}^. The urine, if it has been scanty, 
will now become more so, and may be nearly suppressed ; 
if it has been sufficiently abundant, not unfrequently, as 
the eruption makes its appearance, the urine becomes 
scanty and high-colored. 

In some cases the disease is so mild that there is but 
little disturbance, except that caused by the eruption. In 
other cases the disease is ushered in by violent nervous 
symptoms, such as delirium and coma, accompanied by 
extreme exhaustion, and the patient dies before the erup- 
tion makes its appearance. In other words, the patient 
dies during the period of invasion, from the overwhelming 
of the nervous system with the scarlet fever poison. 

During the earlier stages of the disease the throat symp- 
toms are quite characteristic. Adults and older children 
complain of a pricking sensation in the throat, and difficulty 
in deglutition ; the tonsils, uvula, and posterior wall of the 
pharynx are red and cedematous, and from their appear- 
ance with the attendant symptoms, in most instances, you 
are very early able to decide that the case is one of com- 
mencing scarlatina. There are cases in which the throat 
symptoms are altogether absent at first, and do not come 
on until later in the disease. 

We will now study in detail the symptoms which mark 
the development of this disease. 

As I have already stated, the whole course of scarlet 
fever may conveniently be divided into three stages. 

First, the stage of invasion, or the febrile stage. 

Second, the stage of eruption. 



SYMPTOMS. 313 

Third, the stage of desquamation. 

The duration of the stage of invasion varies in different 
cases according to the type of the disease. In most cases, 
it is from twelve to twenty-four hours ; it may be four or 
five days. Usually the onset is marked by chilliness and 
slight rigor, followed by a rapid rise in temperature. The 
skin becomes dry, the face flushed, and the pulse accelera- 
ted. At the same time there is slight soreness of the throat, 
the face appears red and dry, the neck is stiff, and there is 
some tenderness about the joints. Vomiting and thirst are 
prominent symptoms. The tongue is red at its tip and 
edges, the papillse are enlarged, and it presents the so-called 
strawberry appearance. Lassitude, pain in the head, aching 
of the limbs and restlessness are generally present. There 
may be some delirium at night. 

Twenty-four hours after the commencement of the fever 
of invasion, an eruption makes its appearance, when the 
period of invasion is completed. The period of incubation, 
or the time which elapses between the exposure and the ap- 
pearance of the eruption, varies. By some the eruption is 
said to appear as early as twenty-four hours after exposure, 
while others claim that one or two weeks may elapse after 
the exposure before the disease is developed, that the 
average time is six or seven days. You can make no defi- 
nite statement in regard to the duration of the period be- 
tween the exposure and the appearance of the eruption. 

The eruption first makes its appearance upon the neck 
and upper portion of the chest, and is first seen as little 
red dots, varying in size from a line to a line and a half in 
diameter. These gradually coalesce and the eruption ex- 
tends over the entire surface of the body, perhaps on the 
face, and lastly, it appears on the lower extremities. It 
presents its brightest appearance upon the evening of the 
fourth day. 

On the morning of the fourth day, if you draw your 
finger across the surface, a clear, well-defined line will be 
made, which will remain for some time. The distinct white 
line which follows the finger is a point of some importance 
in distinguishing scarlet fever from roseola, a disease which 



314 SCAELET FEVER. 

has an eruption closely resembling that of scarlet fever. In 
roseola, the well-defined white line produced by drawing 
the finger across the surface will be almost instantly dis- 
placed by the returning redness. It does not remain dis- 
tinct as in scarlatina. The eruption remains visible six or 
seven days. Usually, it begins to fade upon the fourth day, 
and by the sixth day it has entirely disappeared, and des- 
quamation has commenced. The period of desquamation 
lasts about two weeks, during which time there is the great- 
est danger of communicating the disease. At the end of 
that period, if no complication occurs, the patient is well. 
The fine scales which are so abundantly thrown off contain 
the specific poison, and they are so delicate that they are 
blown about with every breath, and carried in every current 
of air, and are in the most favorable condition to be taken 
into the system in the respired air. 

Some have maintained that the contagious period in this 
disease does not occur until the period of desquamation. 
This statement is not sustained by clinical facts. The 
amount of the desquamation depends upon the intensity of 
the eruption. The skin has a dry feel before desquamation 
commences. Where the skin is thin, the epidermis comes 
off in thin scales. Where the skin is thick, as on the palms 
of the hands and soles of the feet, it peels off in extensive 
patches. With the desquamation, the fever subsides more 
or less rapidly. 



LECTURE XXVII. 



SCARLET FEVER. 

Symptoms {continued) . — Complications. — Sequelce. 

I will briefly repeat some tilings said at my last lecture 
in reference to the phenomena which attend the develop- 
ment of scarlet fever. Its symptoms may be divided into 
three stages : a stage of invasion, a stage of eruption, and a 
stage of desquamation. After a variable length of time 
from the exposure, varying from two to six days, the re- 
cipient of the scarlet fever poison begins to have chilly sen- 
sations, alternating with flashes of heat, rarely a distinct 
chill. Following this there is some soreness of the throat, 
headache, pain in the back and limbs ; and the temperature 
rapidly rises, often in twelve hours reaching 104° F. With 
this rise in temperature there is an acceleration of the pulse, 
and not unfrequently very young children will be seized 
with convulsions, rapidly pass into a state of coma, and re- 
main unconscious until the period of eruption. After the 
period of invasion has continued two or three days, a rash 
will appear, first upon the neck and chest ; gradually it 
extends over the face and trunk, then is seen upon the ex- 
tremities. This rash first appears as fine red dots ; these 
dots form patches, which quickly coalesce. 

After the second day of the eruption, if not before, the 
entire surface will present an uniform redness, the color va- 
rying with the severity of the disease. In the milder cases 
you will have a bright rose-red eruption or rash, while in 



316 SCARLET FEVER. 

the severer types the eruption will assume an appearance 
resembling the deep-red color of the boiled lobster. The 
darker the eruption, the more severe the form of the dis- 
ease and the greater the danger. When the eruption is 
fully developed you will notice that the surface is some- 
what elevated, the parts present a swollen appearance, the 
vessels of the skin seem to be congested, and there wiU be 
soreness of the throat more marked than in the febrile 
stage. Usually, vomiting is present at the commencement 
of the disease, but becomes more severe and a more marked 
symptom as the stage of eruption is ushered in ; if not pres- 
ent at the commencement it is certain to make its appear- 
ance with the appearance of the eruption. The vomiting is 
peculiar, not on account of the matters ejected, but the act 
of vomiting is projectile in character. In scarlatina the con- 
dition of the throat depends upon the severity of the dis- 
ease. In some cases there is simply a blush of redness over 
the posterior portion of the pharynx and uvula and ante- 
rior pillars of the soft palate. In other cases you will no- 
tice a general tumefaction of all the soft parts of the throat- 
which can be seen, and the tonsils will be the seat of a more 
or less intense parenchymatous inflammation, which gives 
rise to a swelling that encroaches more or less upon the 
pharynx. Again, you will have ulcerative pharyngitis, as 
it is termed, or upon the surface of the enlarged tonsils and 
swollen mucous membrane of the pharynx you may have 
an exudation, which hereafter will be more fully described. 

In the ordinary form of scarlatina, such as I am now de- 
scribing, when it runs its regular course you will not have 
much swelling of the glands about the neck, nor very much 
tumefaction of the soft tissue in the pharynx. 

The eruption wall reach the maximum of development 
upon the fourth day, and will remain visible six days. 
Generally during this time the temperature continues to 
rise until perhaps it has reached 106° F. or 107° F. In the 
meantime the pulse may increase to 120, or even 140, or per- 
haps 150 beats per minute, and not unfrequently there is 
some delirium during this stage ; there may be also more or 
less stupor. There is an intense itching and burning upon 



IEREGULAEITIES. 317 

the surface, and an intense restlessness depending npon the 
congestion of the cutaneous covering of the body. 

Upon the eighth day of the eruption you will notice that 
the temperature begins to decline, and at the same time it 
can be seen that the eruption has faded in a marked degree 
over the parts where it first made its appearance, especially 
about the neck. This fading of the eruption goes on rap- 
idly, so that by the end of the eighth, certainly early on the 
ninth day, sometimes as early as the sixth day, there is no 
longer any eruption visible on the surface of the body. 

With the disappearance of the rash, desquamation com- 
mences, and with this there will be a still more marked 
fall in temperature and diminished frequency of the pulse. 
All the febrile symptoms disappear, all the throat symptoms 
subside, there is no longer any difficulty in deglutition, 
there is no more pain in the throat, no more swelling 
of the external glands, if previously it had existed. The 
desquamation continues for from fifteen to sixteen days, 
after which time the patient is in a state of convalescence. 

The entire period occupied by a case of scarlet fever when 
it runs its regular course is from two to three weeks. 

Having given you a description of the development of an 
ordinary case of scarlet fever, I must state to you that this 
disease is liable to irregularities in its development and 
course, and to these it is important that I should direct 
your attention. 

It is claimed by some that these irregularities depend 
upon the organ or set of organs primarily affected by the 
scarlet fever poison. They are rather due to some peculi- 
arity in the type of the disease, to the degree of poisoning, 
and in some instances to the particular set of organs that 
are involved in the different epidemics. 

In some epidemics you will see even milder forms of the 
disease than I have yet described. The attack may be so 
mild, and there may be so little fever, that if the eruption 
was not present, you would not be able to recognize the 
scarlet fever ; and even that may be so slight that the stage 
of eruption and the stage of desquamation may pass un- 
noticed, and you may find yourself scarcely able to decide 



318 SCAELET FEVEE. 

whether the patient has, or has not, had an attack of scarlet 
fever 

The most frequent irregularity in the manifestation of 
the disease is noticed in that class of cases where we have 
complications resulting from the overwhelming of the 
cerebro- spinal system with the scarlatina poison. This is 
due to some peculiarity of the poison, and is characteristic 
of certain epidemics. 

In a large number of cases in the febrile stage, especially 
in young children, convulsions may occur, but they do not 
depend upon the peculiarity to which I refer. 

In the class of cases to which reference has been made, 
where complications arise from the overwhelming of the 
cerebro-spinal system with the scarlatina poison, from the 
very onset of the disease there seems to be a tendency to 
stupor and delirium, a peculiar restlessness, an apparent 
wandering, a picking at the bed-clothes, accompanied by a 
peculiarity in the appearance of the eruption, which may 
cause it to assume the boiled-lobster appearance, or even a 
darker hue. The eruption is slow in its development, and 
there is not that uniform redness over the entire body that 
is seen in ordinary cases ; it appears in patches, and with it 
there is exhibited a tendency to blueness of the finger-ends, 
indicating that there is acting upon the nervous system a 
poison which possesses the power of very greatly lowering 
the vitality of the patient. 

There is a class of cases in which there is not much swell- 
ing of the throat, nor is the pulse more frequent than 130 
or 140 per minute, but during the second day of the erup- 
tion the temperature ranges very high, reaching 107° F., or 
108° F. Under such circumstances the disturbance of the 
nervous system is due to the high temperature which may 
have been present for two or three days ; these disturbances 
may be prevented if the temperature is not allowed to rise 
above 103° F. or 104° F. 

Again, in cases where there is marked swelling of the 
throat, and a general infiltration of the tissues and glands 
of the neck, the development of the nervous phenomena is 
due to an interference with the return circulation. The 



IKEEGTTLAKITIES. 319 

condition which gives rise to the cerebral symptoms is one 
of mechanical cerebral congestion, if I may use the term in 
this connection. 

There is still another class of cases in which the marked 
nervous phenomena appear still later in the progress of the 
disease. Under such circumstances they often indicate a 
typhoid condition. This typhoid condition is not induced 
nor are the nervous phenomena developed on account of the 
peculiar effect produced upon the nerve centres by the scar- 
let fever poison, nor are they due to the effects produced by 
a high temperature, nor by an interference with the return 
circulation, but they are due to septic poisoning, a poison- 
ing entirely different from scarlet fever poisoning. The ner- 
vous phenomena develop after the eruption. During the 
developing period, you may have noticed a peculiar icho- 
rous discharge from the nostrils, and frequently you hear 
it said that the patient has become repoisoned by scarlet 
fever poison, but this is not the case ; he has become re- 
poisoned by the septic element of these discharges. 

During the period of desquamation you may have the 
nervous system involved, in consequence of the presence of 
ursemic poisoning. 

The mere terms, scarlatina simplex, scarlatina anginosa, 
and scarlatina maligna, do not indicate all that may be 
included under each division. You must remember that 
scarlatina maligna is that form of the disease in which the 
cerebro-spinal system becomes early involved, in conse- 
quence of some peculiarity of the scarlet fever poison ; or it 
becomes involved while the eruption is being developed, 
and depends upon high temperature ; or it becomes in- 
volved in connection with extreme swelling of the tissue of 
the neck, giving rise to interference of the return cerebral 
circulation, or in consequence of a septic or ursemic ele- 
ment. What the changes are that produce these nervous 
phenomena, when high temperature is present, is still an 
unsettled question. 

Again, scarlet fever may run an irregular course in those 
cases in which there is present an extensive infiltration of 
the tissue of the neck, with inflammatory products, swell- 



320 SCARLET FEVER. 

ing of the glands, and extensive suppuration. Not infre- 
quently these cases terminate fatally ; doubtless in some 
cases the extensive suppuration in the areolar tissue about 
the neck produces this result, and in other cases it is pro- 
duced by the interference with respiration caused by en- 
largement of the gland and swelling of the tissues of the 
neck. In these cases there is a certain amount of danger 
from oedema glottidis, the consequence of extension of the 
inflammation from the adjacent tissues. 

There are cases in which the eruption is not very well 
marked ; the patient passes safely through the stage of 
eruption, and the stage of desquamation is fully estab- 
lished ; but, instead of making a good recovery from this 
point, immense abscesses are rapidly developed in the cervi- 
cal region, blood-changes begin to manifest themselves — 
such changes as allow of the occurrence of hemorrhages — 
and the patient passes into a typhoid condition, with hem- 
orrhages occurring from the nose, mouth, intestines, etc., 
and death ensues. Such a result is produced by the 
peculiar action of the septic poison developed during the 
suppurative process. 

I have already referred to a scarlatinal coryza, in which 
the discharge contains elements capable of producing septic 
poisoning. I have come to regard this coryza as an unfa- 
vorable symptom. The clear serum which runs over the 
lip never causes death ; but the fact that it sometimes pro- 
duces excoriation and ulceration of the tissues with which 
it comes in contact, indicates that there are nasal and 
pharyngeal changes which may destroy life ; especially is 
this the case in young children. 

Sloughing ulcers sometimes develop in the mouth and 
throat ; and, when they do occur, the patient is said to 
have ulcerative stomatitis ; but these ulcerations are really 
due to a peculiarity of the scarlatina poison. Under such 
circumstances, your patient may go on through the period 
of eruption, enter the stage of desquamation, and then 
rapidly sink and die, with symptoms similar to those 
which attend diphtheria. Although the odor of the breath 
may very closely resemble that noticed in some cases of diph- 



SEQUELAE. 321 

theria, there is no diphtheritic exudation present. When 
diphtheria does occur, it is developed as a complication or 
sequela ; it does not belong to the regular history of scarla- 
tina, and is an entirely different disease, depending upon 
an entirely different poison, which makes its appearance 
after the scarlet fever poison has spent itself. Remember 
that scarlatina and diphtheria are distinct diseases, and 
cannot be developed the one from the other, and that the 
condition I have been describing, which resembles diphthe- 
ria, is simply a scarlatinal coryza which indicates the exist- 
ence of sloughing pharyngitis. 

Scarlatina may also be made to run an irregular course 
by the development of inflammation of the internal ear. 
This inflammation extends from the throat up the Eusta- 
chian tube, involves the middle ear, and gives rise to a train 
of symptoms, such as intense pain, delirium, and rolling of 
the head, all of which suggest the presence of acute meningi- 
tis. I recall several instances in which the diagnosis of 
acute meningitis was made, where from the after history of 
the case there was no question but that the symptoms were 
due to such an inflammation of the middle and internal ear. 
When such an inflammation occurs, you should be prepared 
to relieve your patient. The method of procedure for the 
relief of this condition you will learn from lectures in an- 
other department of medicine. 

All these differing conditions I have been describing are 
usually spoken of as complications of scarlet fever, but I 
believe them to be nothing more than a part of the regular 
history of the disease. We find the same thing true in re- 
gard to many other diseases. 

Complications and Sequelae. — I come now to speak of 
those conditions which may be regarded as the sequelae or 
complications of scarlatina. The most common sequela is 
anasarca. The anasarca of scarlatina usually appears at 
the time the patient is convalescing, during the period of 
desquamation, or just as desquamation is being completed. 
It has been commonly believed by the profession that ana- 
sarca is due to some exposure to the influence of cold during 
this period. It is quite possible that the changes in the 
21 



322 SCARLET FEVER. 

kidney which give rise to the anasarca may sometimes be 
produced by the influence of cold, and undoubtedly ana- 
sarca is occasionally developed in this manner, but in the 
majority of cases it is due to some peculiarity in the scarlet 
fever poison, or to some peculiar atmospherical condition. 

During some years anasarca is a very common sequela 
of scarlet fever ; while during other years we have equally 
severe cases of the disease, and yet scarcely a case of ana- 
sarca is seen. While we recognize the fact that it is possible 
for kidney lesions to be developed which shall give rise to 
anasarca in consequence of exposure to cold, it is also of 
importance that we recognize the fact that the lesions and the 
anasarca may be developed independent of such exposure. 
The anasarca first shows itself on the face, and from the face 
it extends over the entire body, and if it becomes general 
you will usually have more or less ascites developed. In 
most cases, at the time or previous to the occurrence of 
the anasarca, you will have certain premonitory symptoms, 
and it is of great importance that you should be familiar 
with these symptoms, and be on the watch for their appear- 
ance. For two or three days previous to their development 
a certain restlessness will be noticed, with nausea and vomit- 
ing. These symptoms are almost universally present. 

The nausea and vomiting so commonly present during 
the earlier periods of the disease have subsided, and now, 
during the period of desquamation or perhaps after it has 
been completed, the vomiting returns. The patient has 
some pain in the head, has loss of appetite, is annoyed by 
the light, does not sleep well, and the temperature is raised 
perhaps two or three degrees. When your patient com- 
plains in this manner during the desquamative stage of scar- 
let fever, your suspicions should be aroused, and if you 
have not already examined his urine you should do so at 
once. It will usually be found scanty and high-colored, 
will contain albumen and casts of the exudative variety, 
and perhaps blood-casts. Occasionally, epithelial casts are 
found; usually, however, these casts are not seen until later 
during the disease. If you have made previous examina- 
tions of the urine before the development of these symp- 



SEQUELS. 323 

toms you may have found renal epithelium, which are 
usually found in any severe case of scarlet fever; but now 
there are present casts which indicate the existence of an 
active inflammatory process in the uriniferous tubules. It 
is not the epithelial desquamation of the tubules, which oc- 
curs in connection with the desquamation which is taking 
place over the entire surface of the body ; but it is a distinct 
sequela of the disease, which shows itself in the form of a 
tubular nephritis. It is possible to have a parenchymatous 
nephritis developed in consequence of exposure to cold 
during this stage of scarlet fever, but this nephritis is due 
to the direct effect of a poison which is acting upon the se- 
creting portion of the kidneys. 

After the anasarca has been present two or three days, if 
the case is to have a favorable termination, the anasarca 
will begin to decline, will be less and less marked about the 
face and feet, the tendency to stupor which has accom- 
panied it will begin to disappear ; and as the dropsy sub- 
sides, and the patient is not so lethargic, the appetite be- 
gins to return, the urine increases in quantity, the albumen 
diminishes, the casts disappear, and convalescence is fully 
established. Anasarca may have been developed, all the 
symptoms have disappeared, and the patient have recov- 
ered within two weeks from the commencement of the at- 
tack. Such anasarca is due to a simple catarrhal inflam- 
mation of the uriniferous tubules, and as complete recovery 
may take place as after an ordinary catarrhal inflammation 
affecting the bronchial tubes. 

If, however, after the anasarca is developed, the case is 
to go on to an unfavorable termination, the anasarca instead 
of diminishing will increase, the face will become more and 
more puffy, the legs more and more cedematous, the abdomen 
more and more distended, the pulse more and more frequent 
and feeble, the temperature more and more elevated, until 
a condition of coma is finally reached, which condition is 
sometimes preceded by convulsions, and followed by death. 

I have given you a brief outline of the usual course of a 
case of scarlatinal nephritis, whether it goes on to recovery 
or to an unfavorable termination. 



324 SCAELET FEVER; 

It is possible for bronchitis or pneumonia to occur as a 
complication of scarlet fever, but they are of rare occur- 
rence. As I have already stated anasarca is the most com- 
mon sequela, and if you will remember when and why it 
appears you will rarely fail to recognize its occurrence. 

Another sequela of scarlatina is inflammation of the 
serous membranes. The serous membrane most liable to 
be involved is the endocardium, and this inflammation may 
pass unrecognized unless you are on the watch for its oc- 
currence, for there may be no rational symptoms present. 
Endocarditis, when it does occur, is liable to be ulcerative in 
character. As the result of such ulcerative endocarditis 
you may have septic symptoms developed, or embolism oc- 
curring in consequence of the removal of a portion of mate- 
rial from the ulcerated valve, and a subsequent plugging 
up of an arterial twig in some distant part of the body. If 
a portion is removed and carried by the circulation into the 
brain, and has been lodged in one of the cerebral vessels, it 
will give rise to sudden coma, and unless you have been 
very closely watching your patient you may be at a loss to 
account for the sudden development of the embolic symp- 
toms in a patient who seemed to be doing well. 

If the endocarditis is not of the ulcerative variety, the 
patient apparently recovers and you discharge him as cured 
of his scarlet fever. Two or three months after his dis- 
charge, he comes back to you complaining of shortness of 
breath, and probably you will suspect and search for 
chronic kidney disease and find no evidence of its existence, 
but you will find the signs of chronic endocarditis, the result 
of the acute endocarditis, which you had failed to recognize. 

Inflammation of the pericardium may occur as a compli- 
cation of scarlet fever, but it does so much less frequently 
than inflammation of the endocardium. Inflammation of 
the pleura, and occasionally inflammation of the peritoneum 
is met with as a sequela of this disease. I have seen death 
caused by an acute peritonitis which occurred as a sequela 
to scarlet fever, but if peritonitis does occur it is much more 
likely to be subacute in character. It is possible to have 
peritonitis developed as a sequela to scarlet fever and to 



SEQUELAE. 325 

be entirely recovered from. I have had two patients re- 
cover who had ascites, the result of subacute peritonitis as 
a sequela of scariet fever. 

Rheumatism may be developed during the desquamative 
period of scarlet fever. Under such circumstances it assumes 
the ordinary appearances of inflammatory rheumatism. 
Quite rapidly it invades one joint after another, the joints 
become red, swollen, and painful, the temperature rises, and 
the pulse becomes accelerated ; but the attack is of short du- 
ration, usually does not last more than four or five days. 
It is not a serious sequela, and complete recovery usually 
occurs within ten or fourteen days from the commencement 
of the attack. 

Suppurative inflammation of the joints sometimes occurs 
as a sequela of scarlet fever. I have seen cases in which 
suppuration of the knee-joint occurred after convalescence 
had been fully established, and all the phenomena of an or- 
dinary attack of suppurative synovitis were presented. 
One case under my care terminated in anchylosis. Such 
suppurative inflammation is not of very frequent occur- 
rence, but it is well you should be aware of the possibility 
of such a sequela. 

Another serious complication of scarlet fever is diphtheria. 
It may occur at any period of the fever, usually it occurs 
during the period of desquamation. There is developed 
the characteristic exudation of the disease, with the atten- 
dant depression noticed in a case of diphtheria developed 
independently of scarlet fever. 

It differs in no respect from primary diphtheria, except in 
the rapidity of its development and in its fatality. In scarlet 
fever there is no more serious complication. When I ob- 
serve a diphtheritic patch in the throat of a scarlet fever 
patient, from that time I regard the case as hopeless. 
Usually it appears quite suddenly, and perhaps does not 
occur more frequently in those who have a severe form of 
the disease than in those who have a mild scarlet fever. 



LECTURE XXVIII 



SCARLET FEVER. 

Differential Diagnosis. — Prognosis. — Treatment 

In the history of scarlet fever we have now come to its 
differential diagnosis. 

Differential Diagnosis. — The diagnosis of scarlet fever 
is usually not difficult after the eruption has made its ap- 
pearance, for, in well-marked cases, that alone will readily 
distinguish it from the other eruptive fevers. At the very 
onset of the eruption, and in irregular cases sometimes the 
differential diagnosis is difficult. The eruptive diseases 
which are most liable to be mistaken for scarlet fever are 
measles, small-pox, roseola, and an erythema which some- 
times appears in surgical cases. In all doubtful cases a 
careful study of the history of the patient is necessary be- 
fore making your diagnosis. 

In measles the appearance of the eruption is preceded by 
a cough and coryza. These symptoms are never present in 
the ushering-in stage of scarlatina. Besides, the eruption 
of measles first appears on the face, whereas the eruption of 
scarlet fever first makes its appearance upon the neck and 
chest. After these diseases are once fully developed, the 
course of the one so differs from that of the other that there 
will rarely be any chance for doubt after the first week of 
the disease. The minute punctate appearance of the scar- 
latina eruption before it becomes confluent is an important 
element in its diagnosis. Although the eruption of conflu- 
ent variola, for the first twenty -four hours, may sometimes 



DIFFERENTIAL DIAGNOSIS. 327 

resemble that of scarlatina, yet the development of the first 
vesicle settles the question. 

The appearance of erythema bears a closer resemblance 
to a perfectly developed scarlatina eruption than does any 
other eruptive disease. It is not, however, present on the 
extremities, neck, and portions of the trunk, and spreads in 
a very irregular manner ; whereas in scarlatina such is not 
the case. But if, on account of the scantiness of the scarla- 
tina eruption, any doubt arises as to the nature of the erup- 
tion, remember that in scarlatina the throat symptoms are 
rarely absent, that usually the tongue presents the straw- 
berry appearance, and that at an early period there is 
usually some swelling of the cervical glands. In those 
cases in which, during the early part of the disease, it is 
impossible to make a differential diagnosis, when the period 
of desquamation is reached the diagnosis will be readily 
made. 

The differential diagnosis between roseola and a very 
mild form of scarlatina is sometimes attended with great 
difficulty. If scarlatina is prevailing, and a child has an 
eruption which lasts for two or three days, then disappears, 
and is not followed by desquamation, you very naturally 
come to the conclusion that the case is one of scarlatina ; 
and yet the sequela proves that the case was one of roseola. 
Such a form of roseola sometimes prevails epidemically, and 
attacks the children in a certain locality, whether they have 
or have not had scarlatina. Under such circumstances, 
adults and children are said to have had a second attack of 
scarlet fever. 

In making a differential diagnosis between this form of 
roseola and scarlatina you must be guided by the duration 
of the eruption and by the character of the throat symp- 
toms. In scarlatina the posterior part of the pharynx is 
affected, while in roseola the redness is confined to the an- 
terior portion ; besides, the throat affection in roseola is 
much milder than in scarlatina. 

One can hardly mistake erysipelas for scarlatina, for 
erysipelas commences at one point and from that point 
gradually extends ; there is also marked oedema of the con- 



328 SCARLET FEVER. 

nective tissue, and there is a very marked difference in the 
constitutional symptoms of the two diseases. 

There are malignant cases of scarlet fever in which no 
eruption appears ; they prove rapidly fatal. In such cases, 
you must be guided in your differential diagnosis by the 
fact that an epidemic of scarlet fever is prevailing (which is 
usually the case), by the rapid development of the disease, 
by the very high range of temperature, and by the very 
grave nervous phenomena ; all of which can only be ac- 
counted for on the ground that your patient is overwhelmed 
by some very active blood-poisoning. 

In no other infectious disease do we have such violent 
symptoms, nor does death take place in so short a time. 

In this class of cases you should frequently examine the 
entire surface of the body, for the eruption is sometimes 
very transient, perhaps appearing only for a few hours on 
the neck or extremities. It is sometimes difficult to draw 
the line of distinction between scarlatina without an erup- 
tion, with swelling of the cervical glands and ulceration of 
the throat, and diphtheria. If a patient has swelling of the 
cervical glands and well-marked febrile symptoms, which 
have come on gradually, that is, have been two or three 
days developing, and yet no scarlatina eruption has ap- 
peared, but a gangrenous ulceration has developed involv- 
ing the tonsils, the posterior wall of the pharynx, and the 
anterior pillar of the soft palate, if scarlet fever is prevailing 
in the locality it is very difficult to decide between it and 
diphtheria. 

There can be no doubt but that scarlatina poison may 
excite a tubular nephritis without an eruption appearing 
upon the surface of the body, or without any of the other 
ordinary symptoms of scarlatina. 

Prognosis. — The prognosis in scarlet fever is always un- 
certain. It will be influenced more by the character of the 
prevailing epidemic than by any other circumstance. 

According to statistics, the rate of mortality ranges from 
one death in five to one in twenty. Some epidemics are very 
mild. During one epidemic, in one month, I treated fifty 
cases of scarlet fever, with only two deaths. During the 



peognosis. 329 

same month of the following year, I treated twenty cases 
with seven deaths. In making yonr prognosis yon mnst 
always take into acconnt the type of the prevailing disease. 
Even when the disease is mild in character, and is running 
a perfectly regular course, dangerous symptoms may sud- 
denly arise without any assignable cause. 

The conditions of a favorable prognosis are as follows : 
when the eruption appears within forty-eight hours from 
the commencement of the attack, and rapidly completes its 
course, reaching its maximum on the second day ; when the 
throat symptoms are mild, little difficulty being experienced 
in swallowing ; when the cervical glands are but slightly 
enlarged ; when the temperature does not rise higher than 
104° F., and the pulse beats only 120 per minute ; when the 
cerebral symptoms are not severe, -and are of short duration ; 
and when the disappearance of the eruption is attended by 
a steady decline in temperature. Even if there is a slight 
affection of the joints and a moderately severe nephritis 
during the period of desquamation, a favorable termination 
may be predicted. The nephritic symptoms will almost 
always entirely disappear during the third or fourth week. 

The conditions for an unfavorable prognosis are : when 
the disease pursues an irregular course ; when the tempera- 
ture rises above 105° F., with dyspnoea and extreme fre- 
quency of the pulse ; when symptoms of collapse come on, 
attended by a cold surface and a small pulse ; when the 
eruption assumes a livid hue, and there are abundant hemor- 
rhages in the skin ; when ulcerative pharyngitis is present, 
especially when it extends to the nasal passages, accom- 
panied by copious coryza and infiltration of the glands and 
tissues of the neck ; when severe nervous symptoms are de- 
veloped with typhoid symptoms ; when there is persistent 
and long- continued vomiting, with diarrhoea coming on at 
the commencement of the attack ; when the nephritic symp- 
toms are early present, and there is general dropsy, exces- 
sive hsematuria, or almost complete suppression of urine, 
with high temperature. 

The occurrence of any of the more serious complications 
to which I have already referred, such as pneumonia, diph- 



330 SCARLET FEVER. 

tlieria, pericarditis, oedema glottidis, etc., always renders 
the prognosis bad. 

Before making yonr prognosis, decide whether the scarlet 
fever is regular or irregular in its course, and if irregular, 
what are the causes of the irregularity. By so doing, you 
will be greatly aided in making your prognosis. It is also 
important to determine your patient's power of resisting 
disease. 

Favorable hygienic surroundings, good nursing, and well- 
directed medical treatment will greatly lessen the death-rate 
in scarlet fever epidemics, and these should be considered 
elements of prognosis. Patients with scarlet fever do better 
when left to themselves than when badly nursed, or when 
under the care of unskilful medical attendants. 

Age is an important element of prognosis. 

The period of greatest mortality is from infancy to five 
years of age. Beyond this period until adult life, the prog- 
nosis is decidedly better. In adults, the mortality is great- 
est in pregnant women, and those who are suffering from 
some organic disease, especially some disease of the heart 
or kidneys. 

Treatment. — In connection with the treatment of this 
affection, the first question that presents itself relates to 
prophylaxis or prevention. 

The prophylaxis of scarlet fever is a system of the strict- 
est quarantine. The sick must be removed from the healthy. 
As in other exanthematous fevers, all useless articles of fur- 
niture must be removed from the sick-room. Fresh air 
renders the contagion of scarlet fever less powerful ; there- 
fore, free ventilation is of the utmost importance. All the 
clothes and excretions of the patient should be disinfected 
in the same manner as in typhoid fever. To prevent the 
dissemination of the dusty particles of the desquamating 
epidermis, during the period of desquamation the surface 
of the body should be frequently sponged, and after each 
sponging the surface should be rubbed with olive oil. 

Those convalescing from this disease should not be allowed 
to leave their apartment until desquamation is completed, 
which usually requires at least three weeks after the com- 



TREATMENT. 331 

mencement of the period of desquamation. The sick-room 
and everything which has been used about the patient 
should be thoroughly disinfected, and the windows and 
doors of the apartment should be allowed to remain open 
for a long time before it is again occupied. 

To prevent the spread of the disease, nurses and atten- 
dants upon the sick should not be allowed to have any 
intercourse with the healthy until the period of desquama- 
tion is passed, and after that time not until there has been 
thorough cleaning and disinfecting. It is doubtful whether 
the funerals of those dying of scarlet fever should be public. 

There is no known prophylactic treatment, except iso- 
lation, and a thorough disinfection of everything contami- 
nated by the contagion. 

A theory has been advanced that belladonna has power to 
prevent the development of this disease in those who have 
been exposed to its contagious influence. This drug has 
been very extensively administered in order to test its effects 
as a preventive in scarlet fever. 

After having carefully examined the subject, both in its 
literature and clinically, I am convinced that belladonna 
has no power to prevent the development or mitigate the 
severity of the fever in those who have been exposed to its 
infection. As I have already said, fresh air is the only 
agent of which we have any knowledge, which can render 
the contagious influence of this fever less powerful. 

Medicinal Treatment. — The medicinal treatment of 
scarlet fever is almost entirely expectant. It must be re- 
membered that it is a disease which cannot be aborted, and 
which, if left to its natural course, tends to recovery if the 
fever and the local symptoms remain within certain bounds. 
It has certain stages to pass through, and you cannot safely 
interfere with its regular course. Your province is to stand 
by and watch, and, so far as possible, guard against com- 
plications ; if they occur you are able to afford a certain 
amount of relief. 

There are certain details which it is important to attend 
to. The bed and body linen should be frequently changed. 
As soon as the period of desquamation has been reached the 



332 SCAKLET FEVER. 

patient should have a warm bath once or twice daring the 
day, the surface of the body being well washed with car- 
bolized soap. The baths hasten the process of desquamation 
and aid in bringing the skin into a healthy condition as 
rapidly as possible ; the kidneys will also be relieved, and 
you may prevent serious lesions from these organs. Such 
general means as are applicable in the treatment of all fevers 
may be employed. If the temperature of the patient rises 
above 103° F., certainly if it rises above 104° F., it is impor- 
tant that some measures be resorted to for its reduction. 
The temperature should never be allowed to remain at 104° 
F. longer than twenty-four hours. 

The means which are to be employed to accomplish this 
reduction are the antipyretic measures already referred to, 
such as the application of cold to the surface by means of 
sponging and baths, and the administration of large doses 
of quinine. 

There is a strong prejudice against the application of cold 
to the surface of the body in scarlet fever. I am by no 
means certain that cold baths are always safe, or that in all 
cases the application of cold to the surface is judicious 
treatment. 

At the present day, we are told that the kidneys will be 
most readily relieved of the scarlet fever poison when cold is 
used for the purpose of reducing the temperature, and that 
we should make use of this agent rather than permit the 
case to go on without effecting such a reduction. 

It is claimed that when the temperature of a patient is 
kept below 103° F., scarlatina nephritis rarely occurs. This 
statement is not sustained by facts ; it has been found that 
kidney complications are as extensive in the cases where 
cold is employed as in those cases where the temperature 
ranges higher and cold to the surface is not employed. 

We should be governed by the same rules in the appli- 
cation of cold to the surface in scarlet fever as govern us in 
the treatment of typhus and typhoid fevers. 

With regard to the use of quinine as an antipyretic, I 
need add nothing to what has already been said in connec- 
tion with its antipyretic power in the treatment of other 



TREATMENT. 333 

fevers. It has the same power of reducing temperature in 
scarlet fever that it has in typhoid fever. 

Unless the temperature in a case of scarlet fever ranges 
above 105° F., do not apply cold to the surface, nor give 
quinine in antipyretic doses. With such a temperature 
there will probably be delirium, but it must be regarded as 
one of the phenomena of the disease, requiring no special 
treatment. If the temperature rises above 105° F., perhaps 
reaches 106° F. or 107° F., and the patient manifests the 
nervous phenomena which have been referred to, such as 
restlessness, tossing, blueness of the surface, tendency to 
coma, etc., your duty is to reduce the temperature either 
by the application of cold to the surface or by the admin- 
istration of one or two antipyretic doses of quinine. In all 
cases, let the patient be sponged frequently with tepid 
water, and if there is intense burning of the surface, add 
a saline to the water. Sponging in this manner will give 
the patient very great comfort. Some have advised that 
the surface be anointed with oil for the relief of the burn- 
ing. My own experience has led me to rely upon simple 
tepid saline water. I have found that it gives patients 
greater relief, is more easily applied, and in its use is more 
agreeable than any of the substances which have been used 
for this purpose. I have not found that the application of 
oil to the surface has any effect in controlling the tempera- 
ture, nor does it seem to have any effect on the process of 
desquamation, and as soon as desquamation commences, the 
process should be assisted by frequent washings with soap 
and water. For the throat complications, which will give 
you more or less trouble in all severe cases, especially 
when there is much enlargement of the glands at the angle 
of the jaw, causing difficulty in swallowing, leeches were 
formerly employed, but their use has now been almost en- 
tirely abandoned. The vitality of the patient is lessened 
by their use, and on this account they are contra-indicated. 
Of all the remedies which I have employed for the relief of 
throat complications, I think cold carbonic acid water the 
best. Whether it does more than afford relief, -I am not 
able to say, but I am certain that cold carbonic acid water 



334 SCAKLET FEVER. 

or pieces of ice held in the month, and brought as much as 
possible in contact with the swollen mucous membrane of 
the throat, when used early, afford most marked relief. 
In the advanced stages of the disease, where there is great 
infiltration of the glands and tissues about the neck, cold 
applications do not afford the same relief as when they 
are used in the early stage; then cloths wrung out in 
tepid water and applied to the surface seem to be of ser- 
vice. During this stage, hot applications are generally 
much more agreeable to the patient. You may cover the 
hot cloths with oil-silk. These applications will not hasten 
the suppurative process, unless suppuration is already 
established. While using hot applications externally, warm 
water gargles and steam inhalations may be used internally. 
Of these methods of treating throat affections, adopt the 
one which seems to you to be the most rational plan of 
treatment. In scarlet fever I favor the use of hot rather 
than cold applications. Whichever you use, use it to the 
exclusion of the other ; either cold internally and externally, 
or heat internally and externally. 

There are different opinions in regard to the action of 
heat and cold. Some claim that their action is the same. 

The superficial and deep ulcers which are sometimes seen 
in the throat of scarlet fever patients can best be treated by 
spraying them with carbolic acid, muriated tincture of iron, 
chlorate of potash, tannic acid, or any of that class of reme- 
dies. Whatever remedy }^ou may choose, it can be much 
more successfully applied by means of spray than by a 
camel' s-hair brush or a probang. Such local remedies thus 
applied afford great relief. The pain from these ulcerations 
is sometimes very severe, and you will be obliged to resort 
to some measure for its relief. Bromide of potassium, 
ether, and other anodyne applications in the form of spray 
may be made with satisfactory results. 

In a certain class of cases, where there is marked disturb- 
ance of the nervous system, accompanied by great depres- 
sion of the vital and feeble heart action, you will be obliged 
early to resort to the use of stimulants. It is not necessary 
to wait until a certain stage of the eruption or of the dis- 



TREATMENT. 335 

ease is reached before commencing their administration. It 
may be necessary to resort to their use within twelve hours, 
or even within a less time, from the commencement of the 
attack. In some cases yon will rely almost entirely on the 
beneficial effect that may be produced by the free and early 
administration of stimulants. The approach of kidney se- 
quela in scarlet fever will be indicated by the development 
of those premonitory symptoms which precede the ana- 
sarca ; and whenever such symptoms are developed, you 
should apply dry or wet cups, according to the condition 
of the patient, over the region of the kidneys, upon either 
side of the spine. Apply three or four cups on each side, 
and follow their application with hot fomentations over the 
kidneys. At the same time raise the temperature of the 
sick-room to 73° F. or 74° F., cover the body of the patient 
with flannel, administer hot-air or warm baths, and early 
commence the administration of diuretics. Of these, digi- 
talis will act most favorably. If the anasarca does not dis- 
appear under the influence of the digitalis and the other 
means employed, calomel may be combined with the digi- 
talis, and its use continued for a few days. Why the 
action of diuretics is increased by having a mercurial com- 
bined with them I am unable to say ; but the fact is well 
established that, in certain cases — when the patient is going 
on from bad to worse, when the anasarca is increasing, the 
tendency to coma is becoming more and more marked, indi- 
cating an nnfavorable termination to the case, and cups 
have been applied, hot baths, and diuretics employed with 
no satisfactory result — if small doses of calomel are com- 
bined with the diuretics, and their use continued for two or 
three days, the entire phase of the case may be changed. 

In conjunction with the measures recommended, let the 
patient drink as freely as possible of water. If convulsions 
occur, or threatening symptoms indicating the approach of 
convulsions, are developed, you will be justified in resort- 
ing to the nse of opium, either hypodermically or by the 
mouth. Under such circumstances the effect of opium is 
often most satisfactory. It not only arrests the convulsive 
tendencies, but produces the most profuse diaphoresis, and 



336 SCAELET FEVER. 

aids in restoring the renal functions. With this class of 
patients I am confident that I have saved life by the timely 
use of opium. In my published articles on Blight's disease 
I have very fully discussed the subject, and given the rea- 
sons for its administration. 

It is unnecessary for me to detain you with the special 
treatment of the different complications which I have stated 
as liable to occur in scarlet fever. The treatment of each 
complication will be indicated by the character and severity 
of the complication. 

There are many other minor points in the management of 
this disease. I have given you an outline which I think 
will enable you to fully appreciate the general indications, 
and I must leave many of the details of treatment to your 
own study and experience. 



LECTURE XXIX. 



MEASLES. 

Morbid Anatomy. — Etiology. — Symptoms. 

We row come to the study of another exanthematous 
fever, namely, measles or rubeola. This is of much more 
frequent occurrence than any of the fevers which have been 
engaging our attention. It is a disease from which few per- 
sons escape. It is essentially a disease of childhood, but it 
may occur at any age ; it is, however, less liable to occur in 
young infants than in children after the period of dentition. 
A second attack is of rare occurrence. It is characterized 
by an eruption of red spots, accompanied by a catarrh of 
the mucous membrane of the air-passages, and a more or 
less severe fever. It may prevail as an epidemic or endemic 
disease, and not infrequently there are sporadic cases of 
measles. 

Mokbtd Anatomy. — The anatomical lesions of measles, 

with the exception of the eruption, are similar to those of 

small-pox and scarlatina. There are the same changes in 

the blood ; it is dark-colored and fluid, poor in fibrin, and in 

severe cases shows a tendency to infiltrate the tissues. The 

number of red globules are diminished, and the white ones 

are increased. There is the same tendencv to congestion of 

the internal organs. The spleen and liver are moderately 

enlarged. The mucous membrane of the nose, pharynx, 

larynx, and larger bronchi, as well as the conjunctivae, are 

more or less intensely congested, and present all the ana- 
22 



338 MEASLES. 

tomical changes of acute catarrh. In the majority of 
instances this catarrh is most severe just before and during 
the early period of the eruption; generally, it begins to dis- 
appear when the eruption has reached its height, and within 
two or three days entirely disappears. Where death has 
resulted from measles, in the majority of autopsies you 
will find evidences of capillary bronchitis, and not infre- 
quently evidences of catarrhal pneumonia. Strictly speak- 
ing, these are not anatomical lesions of measles, but 
complications ; they are, however, such frequent attendants 
of this disease, that they almost become a part of its his- 
tory. Catarrhal affections of the respiratory organs are 
rather characteristic of the measles. The eruption of 
measles is papular ; the papules first show themselves upon 
the face, especially upon the chin ; gradually they extend to 
all parts of the body, until lastly they are seen upon the 
back of the hands. When the eruption is well developed 
the spots are slightly elevated, and have a diameter varying 
from one- tenth to one- twentieth of an inch ; in form they 
are crescent-shaped, their margins are sharply defined, 
usually their color is of a bright red, sometimes shading off 
into blue. In most cases the spots are distinct and sepa- 
rated from each other by pale tracts of skin ; they may 
become confluent, and thus give to the surface an uniform 
redness. When this occurs the surface presents an appear- 
ance similar to that seen in scarlatina. The earlier papule 
in each spot usually occupies the place of a hair-follicle. 
The spots disappear on pressure, but immediately return 
when the pressure is removed. Sometimes each spot con- 
tains several papules. The diversity in form and appearance 
of measle spots in different cases depends upon deviations 
in size, elevation, and grouping of the papules. When the 
spots assume a dark-red color, and do not disappear on 
pressure, capillary hemorrhages have taken place into the 
papules, and the eruption is called hemorrhagic. When 
the eruption is very abundant, little vesicles sometimes 
appear upon the papules, especially upon the trunk when 
there has been profuse perspiration. As soon as the spots 
have reached their maximum of development, their color 



ETIOLOGY. 339 

begins to fade ; the fading is progressive, the centre of the 
spots longest retain their redness ; the elevations subside 
with loss of color. In a varying time, from one to five days, 
the spots entirely disappear, leaving a yellowish or brownish 
stain. This staining is due to pigmentation of the skin, and 
is sometimes visible for two weeks. Exfoliation of the epi- 
dermis or desquamation takes place only upon the sides of 
the measle spots ; it is never so extensive as in scarlet fever. 
The skin does not desquamate in layers, but in fine brown 
scales. It may commence before the redness of the eruption 
disappears, but it does not usually occur until the erup- 
tion has entirely faded. In most cases the period of des- 
quamation is short, rarely lasting a week. 

Etiology. — As regards the etiology of measles, experience 
teaches that it is essentially a contagious disease. So far 
as has yet been determined, it is only propagated by con- 
tagion. There are places, extensive districts, and countries 
thickly inhabited, where this disease has never prevailed. 
There is no authentic evidence that it ever originated spon- 
taneously. 

A few years ago, one of our own countrymen announced 
that he had found in decaying straw a peculiar growth or 
fungus which had the power of developing measles. 

During the late war we frequently heard of "straw 
measles." When the surface of the body was brought 
in contact with a fungus found upon decaying straw, an 
eruption was developed. The eruption was not that of 
measles. It had no power of propagating itself, and could 
not be conveyed from one individual to another. 

The question has often been asked, where is the poison 
of measles located % I answer, either in the mucous secre- 
tion, or in the exhalations from the body of the infected, so 
contaminating the air about the sick, that when persons 
who have not had the disease are brought within its influ- 
ence, measles will be developed. It has been proved that 
the blood, the mucous secretions, and even the tears have 
the power of conveying the disease by inoculation. I sup- 
pose there is little question but that the disease can be con- 
veyed in clothing, or, in other words, that it is a portable 



340 MEASLES. 

disease. I regard trie infection of measles as more tena- 
cious, so to speak, than that of small-pox or scarlet fever. 
That is, a person not protected when exposed to measles is 
much more certain to contract the disease than is an unpro- 
tected person to contract small-pox or scarlet fever, the 
same circumstances surrounding the exposure. It is pos- 
sible for the infection to be conveyed from one place to 
another in clothing and in fluids. I know of one instance 
in which it was brought to a family in cow's milk. The 
exact nature of this poison is still unknown. 

It has been claimed that a certain cell has been found, a 
cell with a tail-like end, movable and colorless, which has 
the power of developing measles, but these statements have 
never been substantiated, and like the theory that the 
syphilitic cell was the active agent in the development 
of syphilis, this theory of development still lacks facts to 
sustain it. 

The microscope has not as yet revealed the contagion of 
this disease. All that can be said with positiveness concern- 
ing its nature is, that there is an impalpable virus which 
may be conveyed from an affected to an unaffected person, 
and when received into the body of an individual who is 
not protected from the contagion by a previous attack, 
after a certain period, varying in length from eight to four- 
teen days, it produces the phenomena which characterize 
the disease. Some claim that the poison may remain sixteen 
days in the system before the phenomena of the disease 
are developed. One case is recorded in which the disease 
is said to have been developed fifty days after exposure. 

This period is termed the " period of incubation," audits 
average duration is eight days. During this period the 
poison remains latent, giving its possessor no knowledge of 
its presence. 

In most cases a slight exposure is sufficient to induce the 
disease ; in some cases it is contracted only after prolonged 
exposure. 

Susceptibility to this contagion is almost universal. All 
classes are equally subject to the infection. Second attacks 
are exceedingly rare. 



SYMPTOMS. 341 

The exact time in the course of the disease when measles 
is most infectious is not definitely determined. Statistics 
furnish almost absolute proof that it may infect through- 
out its entire course, in the precursory, eruptive, and des- 
quamative stage. 

Symptoms. — Measles, like the other exanthematous fevers, 
if uncomplicated, runs a definite course. I shall describe 
the course of an uncomplicated case of ordinary severity. 

As I have already stated, the stage of incubation is the 
latent period of the disease, without fever, and free from 
local symptoms. 

Premonitory or precursory stage. — At the end of this 
period, or from eight to ten days after exposure, the pa- 
tient begins to suffer from coryza, is languid, chilly, and 
exceedingly irritable. Occasionally, in young children, 
convulsions occur. The coryza and other catarrhal symp- 
toms, at first, may or may not be accompanied by fever. 
Very soon they will be followed, if they are not accompanied, 
by a marked febrile movement. The eyes will be injected 
and watery, there will be a burning sensation and an aver- 
sion to light, and the eyelids will be red and tumefied. 
There is a constant, irritating, watery discharge from the 
nose, with frequent sneezing and pain over the frontal si- 
nuses. Sore throat is complained of, and the voice is a little 
husky. Bronchial catarrh is indicated by uneasiness and 
constriction over the chest, with a frequent, dry, hoarse 
cough, hurried respiration, etc. The suffused, red appear- 
ance of the eyes is peculiar, and distinguishes measles from 
scarlet fever and other forms of eruptive fever. After the 
early symptoms have continued perhaps for twenty-four 
hours, perhaps no more than two or three hours, an initial 
fever will be developed, which, with the catarrhal symp- 
toms, continues for about forty-eight hours ; then the erup- 
tion makes its appearance. 

Eruptive stage. — The eruption is first seen upon the face, 
then upon the neck, then upon the chest and over the body, 
afterwards upon the legs and arms, and lastly, upon the 
back of the hand. Usually it is about four days from the 
time of the appearance of the eruption upon the face be- 



342 MEASLES. 

fore it has passed over the entire body, and it begins to 
fade from any one part about thirty-six hours from the 
time of its appearance upon that part ; first, it begins to 
fade from the face, then the neck and chest, and finally 
from the back of the hands. If you closely examine the 
eruption it will be found composed of little fine red dots, 
which, after a little time, will be seen crowded together in 
patches of irregular shape. Usually these patches are 
crescentic in shape, and between them will be skin having 
its natural appearance. In this respect, the eruption dif- 
fers from that of scarlet fever. In scarlet fever there is a 
uniform blush or redness, and when the eruption is present 
no portion of the skin remains unaffected. 

The eruption of measles presents more of a papillary ap- 
pearance upon the face than upon any other part of the 
body. 

With the appearance of the eruption there is more or 
less swelling of the surface, itching and burning, and the 
color of the eruption will vary from a bright rose red to a 
dark mahogany hue. The difference in color depends upon 
the condition of the individual and the peculiarity of the 
type of the disease, rather than upon any change in the 
skin itself. As the eruption disappears it loses its bright 
red color, and becomes a yellowish-red, until, finally, noth- 
ing but a staining of the surface is left, then desquamation 
commences. 

Desquamative Stage. — The desquamation which follows 
the eruption is not like the desquamation of scarlet fever, 
occurring in patches, but it occurs in very fine dust-like 
flakes, which may pass unobserved. The eruption reaches 
its height by the third day from the time of its appearance, 
and generally has disappeared by the end of the sixth day. 
As a rule, during the development of the eruption, the 
catarrhal symptoms and fever are increased in intensity ; 
the patient will sneeze and cough, and frequently with such 
severity, and with such a coarse, grating, brassy tone, that 
it has received the name of " iron cougli." It is not the 
cough of croup, there is no stridulous breathing accompa- 
nying it, but it is the result of an ordinary catarrhal laryn- 



IRREGULARITIES. 343 

gitis, which causes the patient to cough perhaps for two or 
three days without expectoration, or any attempt at expec- 
toration. During this period the pulse will range from 100 
to 120 beats per minute, and in young children may reach 
160 beats per minute. In the majority of cases, the tempe- 
rature does not rise above 103° F., but it may rise as high as 
106° F. or 107° F. As soon as the eruption begins to decline, 
a marked effect will be produced, and usually the tempera- 
ture falls two or three degrees. As the decline in the erup- 
tion goes on, the temperature gradually falls, until, by the 
time the eruption has entirely disappeared, the patient will 
be fully convalescent. 

Such is a brief description of the eruption, and the symp- 
toms accompanying it, when measles runs its regular course. 
There are certain irregular modes of development which you 
will do well to remember. 

We have different varieties of measles, if we may regard 
them as varieties. 

We have, first, the regular form of measles, which we 
have just been considering, in which the disease runs a 
regular course, and the eruption has its regular stages of 
development. Then, when measles is prevailing in a local- 
ity, you will meet with cases in which all the catarrhal 
symptoms of the disease are present, without an eruption. 
You will also meet with cases in which there is an eruption 
closely resembling that of measles, with no catarrhal symp- 
toms ; from the appearance of the eruption, you will not be 
able to say whether the patient has or has not measles ; if 
he has been exposed to the contagion of the disease you 
will be inclined to regard the case as one of measles, and 
yet if there are no catarrhal symptoms, but simply an erup- 
tion, I should hardly be willing to make such a diagnosis. 
There is a form of roseola which very closely resembles 
measles in every aspect of the disease, except the catarrhal 
symptoms. 

There is an irregular form of measles which prevails epi- 
demically, which is characterized by a tendency to ulcera- 
tion of mucous surfaces. This form shows its peculiar ten- 
dency by the development of ulcers at the angle of the 



344 MEASLES. 

mouth, within the nose, around the vulva, anus, etc. Some- 
times these ulcers spread and so interfere with deglutition 
and respiration as to endanger life. The ulcerations are 
accompanied by great prostration of the vital powers and a 
tendency to gangrene. This irregular variety only occurs 
in those who are poorly nourished, live in badly ventilated 
houses, and are surrounded by unfavorable hygienic influ- 
ences. 

Again, there is another form of measles in which, at the 
very onset of the disease, there is a very high range of 
temperature. You will have no more severe catarrhal 
symptoms than in the ordinary forms — no more bronchitis ; 
but there will be more fever and a higher range of tem- 
perature, the temperature perhaps ranging as high as 106° 
F. or 107° F. Associated with this elevation of tempera- 
ture, there will be a restlessness, a dry tongue, and, very 
soon after the appearance of the dry tongue, a change in 
the color of the eruption, and it will assume a dusky, pur- 
plish hue. The eruption may present this peculiar appear- 
ance at the very commencement of its development. This 
type of measles is called u ~blac7t measles." The color of 
the eruption simply shows that there have been extensive 
blood-changes. In most cases, quite probably, these 
changes have taken place prior to the development of the 
eruption. By some it has been claimed that there is at 
work a peculiar epidemic or endemic influence that gives 
rise to the peculiar type of the disease ; but, as I have been 
brought in contact with it, it has seemed to me that it dif- 
fered from tlm ordinary type only in the intensity of the 
fever. It is the high range of temperature which stamps it 
as a peculiar type of the disease ; but, as soon as the erup- 
tion has made its appearance, although at first it may be of 
a bright red color, within a day or two it assumes the 
peculiar dusky black appearance which has given rise to 
the name it has received. 

There is another irregular form of measles, in which the 
eruption is largely made up of petechial spots scattered 
over the surface of the body, which are due to a hemor- 
rhagic diathesis. It is really a hemorrhagic form of measles, 



COMPLICATIONS. 345 

and is a very unfavorable type of the disease. At first the 
eruption presents the same appearance as the ordinary 
eruption of measles ; but, after the fever has continued a 
few days, it assumes a dark color, the patient becomes 
restless, the tongue dry, there may be vomiting and diar- 
rhoea, and, if death occurs, at the post-mortem examination 
you will find that the anatomical lesions very closely re- 
semble those found at the post-mortem examination of one 
who has died from typhoid fever, such as changes in the 
spleen and elevation of Peyer's patches. These cases are 
also known by the term " black measles." We have, then, 
two forms of black measles — one in which the eruption 
consists of petechial spots scattered over the surface, and 
dependent upon a hemorrhagic tendency ; in the other 
form the eruption assumes a dark appearance, on account 
of changes which have occurred in the blood, the result of 
a very high degree of temperature at an early period of the 
attack. 

I have thus briefly spoken to you of the most frequent 
irregularities in the course of this disease. There is always 
more or less danger connected with any of the more severe 
forms of irregular development. Although measles is usu- 
ally not a disease of much severity, yet you must remember 
that, however mild the type may be, the disease is liable to 
be complicated, and the most frequent complications are to 
be found in the respiratory organs. 

Complications. — Of these the most important is capillary 
bronchitis. You will rarely have a case of measles without 
more or less bronchial catarrh, but the bronchial catarrh 
which ordinarily attends it is not of much consequence. 
When, however, you find that the bronchitis is becoming 
capillary, you must recognize the fact that the patient is in 
great danger. Upon auscultation, if instead of loud, 
sonorous rales, which indicate that the catarrh is confined 
to the larger bronchial tubes, you have fine crackling 
sounds, accompanied by an entire loss of or an extremely 
feeble vesicular murmur, you may be certain that the ca- 
tarrhal inflammation has extended into the finer bronchial 
tubes, and when, in connection with this disease, these are 



346 MEASLES. 

invaded, you should remember that there is always great 
danger of the plugging up of the fine bronchial tubes. 
This will almost certainly be followed by a lobular collapse, 
and a subsequent development of lobular pneumonia. 

A catarrhal pneumonia which complicates measles is 
always attended with great danger. 

As a rule, it attacks both lower lobes at the same time, 
especially their dorsal aspect, while in the upper lobes only 
a few tubes are involved. This complication may occur at 
any time during the course of measles, but it is more liable 
to occur just after the eruptive stage. Its development 
always increases the fever in proportion to the extent of 
lung involved. 

Desquamative nephritis may occur as a complication, but 
is not of as frequent occurrence as in scarlet fever. You 
will rarely have anasarca or the other attendants of scar- 
latinal nephritis. 

Secondary meningitis not infrequently occurs as a com- 
plication in measles. When it does occur, it is developed 
during the period in which the eruption is disappearing. It 
is more likely to occur in this disease than in scarlet fever. 

In connection with measles you will have what may be 
regarded as a sequela, a mild form of ophthalmia. This 
ophthalmia may considerably inconvenience the patient, and 
lead to permanent injury of the eyes. It is especially im- 
portant that you should remember that it appears during the 
convalescing period, that it is a conjunctivitis, and usually 
entirely disappears if the eyes are frequently bathed with 
warm water and properly protected from the light. 

Otorrhcea, or inflammation of the external ear, is another 
complication, or rather sequela of measles. It most com- 
monly appears in those patients who have what is called a 
strumous diathesis, have phthisical parents, are themselves 
badly nourished, and have suffered from a severe form of 
measles. This otorrhcea is sometimes very obstinate, and 
if it yields to treatment, does so very tardily. 

In adults, acute miliary tuberculosis not infrequently 
occurs as a sequela of measles. This is the unqualified 
statement of the books. 



COMPLICATIONS. 347 

Within the past two years I have seen two cases of what, 
previous to death, seemed to be acute tuberculosis, and 
when the autopsy was made, throughout the lung sub- 
stance here and there were little points or nodules which 
presented the usual appearance of miliary tubercles, but, 
when microscopically examined, they were found to be 
points of vesicular pneumonia. These two patients really 
died from pneumonia, and not from acute tuberculosis, 
although the lungs presented the appearances ordinarily 
seen in connection with acute tuberculosis. 

The gross appearance of the lungs so closely resembles 
lungs that are the seat of acute tuberculosis, that it is diffi- 
cult with the naked eye to distinguish the one from the 
other. 

The mucous membrane of the intestinal canal may also 
become the seat of important complications in measles. A 
mild form of gastric catarrh is of quite frequent occurrence, 
but is rarely serious in character. Severe intestinal catarrhs, 
giving rise to troublesome diarrhoea and dysentery, are 
sometimes very serious complications, especially in very 
young and feeble children. Occasionally malignant epi- 
demics of measles prevail, during which fatal results are 
chiefly due to intestinal catarrhs. 

Diphtheria does not so frequently complicate measles as 
it does scarlet fever. It generally makes its appearance at 
the acme of the eruption, and when severe its occurrence is 
marked by a rapid rise in temperature. The symptoms of 
the diphtheria are the same as when it occurs as a primary 
disease. Inspection shows the diphtheritic exudation on 
the tonsils and pharynx, accompanied by all the attendant 
phenomena of ordinary diphtheria. Sometimes the diph- 
theritic exudation appears on the labia of the female, and 
on the genitals of the male. It must always be regarded as 
a serious complication. 

ISTot unfrequently measles leaves the patient in a state of 
general ill-health. Especially is this the case in scrofulous 
and rachitic children. 



LECTURE XXX 



MEASLES. 



Differential Diagnosis. — Prognosis. — Treatment. — Rose- 
ola. — Miliary Fever. 

We will continue the history of measles, and this morn- 
ing I invite your attention to its differential diagnosis. 

Differential Diagnosis. — Ordinarily, when the erup- 
tion is well defined, the diagnosis of measles is not difficult. 
In some cases, however, the eruption presents an appear- 
ance which closely resembles that of the eruption of scarlet 
fever and roseola. 

As I have already stated, in nearly every case of measles 
the catarrhal symptoms precede and accompany the pre- 
cursory stage, and increase in severity during the period 
of eruption. The presence or absence of these catarrhal 
symptoms will enable you in the majority of cases to make 
a differential diagnosis. 

It has been said that the line of distinction between 
measles and scarlet fever may be easily drawn ; that if in 
scarlet fever you pass your finger-nail lightly over any por- 
tion of the surface of the body, a white line will remain, 
which will immediately again become red. Whereas in 
measles no mark will usually be left ; but, if a white line 
does remain, the color produced is more permanent than in 
scarlet fever. In well-marked cases this appearance may 
settle the question of diagnosis, but in those cases in which 
the eruption of measles closely resembles that of scarlatina, 



DIFFERENTIAL DIAGNOSIS. — PROGNOSIS. 349 

we are compelled to rely upon the presence or absence of 
catarrhal symptoms and the appearance of the throat. In 
children, the eruption of typhus fever very frequently 
closely resembles that of measles, but it does not appear 
upon the face, and is not accompanied by catarrhal symp- 
toms. In typhus fever, quite frequently, nervous symp- 
toms are present, such as delirium, prostration, and ten- 
dency to coma. Such symptoms are only met with in the 
hemorrhagic or typhoid variety of measles. Before the ap- 
pearance of the eruption a careful examination of the mu- 
cous membrane of the pharynx will settle the question of 
diagnosis. In measles the mucous surface will be more or 
less intensely injected ; in typhus fever it will not be so 
injected. 

The differential diagnosis between measles and small-pox 
has already been considered. There will certainly be no 
difficulty in making a diagnosis, if you wait until the third 
day of the eruption ; then the small-pox vesicle is formed. 
The same is true of varicella and other vesicular diseases. 

The eruption of measles differs from that of roseola. In 
measles it is partially confluent, in roseola it is non-conflu- 
ent. In roseola the mucous membrane of the fauces is not 
intensely injected. In measles the fever runs a characteris- 
tic course. If the temperature is normal, if the eruption on 
the trunk is of a bright red color, if the surface is smooth, 
and if catarrhal- symptoms are absent, you may exclude 
measles. The non-contagious character of roseola is an im- 
portant element of differential diagnosis. 

It is hardly possible to mistake syphilitic exanthemata 
for measles, for there are certain glandular changes which 
attend the development of syphilitic eruptions which estab- 
lish the diagnosis. In the early period of the disease, when 
coryza is a prominent symptom, before the appearance of 
the eruption, measles may be mistaken for an ordinary in- 
fluenza. 

Prognosis. — The prognosis in uncomplicated measles is 
always good. Any irregularity in its development, and 
dentition in children, may render the prognosis unfavora- 
ble. In the hemorrhagic, in the ulcerative, and in the ty- 



350 MEASLES. 

plioid variety, or black measles, as it is termed, the prog- 
nosis is grave. Measles occurring in pregnancy almost 
invariably prove fatal. 

In severe cases, the deviations from the typical course of 
the disease which render the prognosis unfavorable are a 
temperature of 105° F. or 106° F., during the period of ini- 
tiatory fever, a retardation or an irregularity in the appear- 
ance of the eruption at the beginning of the eruptive stage, 
and the occurrence of complications, especially broncho- 
pneumonia, croupous laryngitis, and diphtheria. 

Profuse hemorrhages from the mucous surfaces during 
any period of the fever, render the prognosis unfavorable. 

The hygienic surroundings of the patient greatly influence 
the prognosis. 

The prognosis also depends upon the age of the patient ; 
the rate of mortality is much greater among adults than 
children. The character of the prevailing epidemic deter- 
mines to a very great degree the prognosis. 

When measles is developed in one who is suffering from 
a severe chronic disease, especially some organic disease of 
the lungs, the prognosis is unfavorable. The patient will 
not probably die during the active period of the measles, 
but the chronic pulmonary disease may terminate fatally 
from the effect produced by the sequelse of measles. For 
instance, a person has evidences of consolidation about the 
apex of the lung, a condition which justifies a favorable 
prognosis ; let measles be developed in this same person, 
and capillary bronchitis, terminating in a more or less ex- 
tensive pneumonia, will probably occur, from which acute 
phthisis may be developed. 

In measles, death rarely occurs during the first week of 
the disease ; it usually takes place during the second week ; 
if serious complications occur, it may take place later in 
the disease. 

Treatment. — The prophylactic treatment of measles con- 
sists in isolating the affected person. 

When the disease runs its regular course, the principal 
duty of the physician is to watch for and guard against the 
occurrence of pulmonary complications. As regards treat- 



TKEATMENT, 351 

ment, all that is necessary is to place the patient in a large, 
well-ventilated room, with the temperature of 63° F. or 65° 
F. The diet should be milk. The room should be darkened, 
so that the congested conjunctivae may not be exposed to 
light. If the patient complains of itching and burning of 
the surface, he maybe frequently sponged with tepid water, 
this causes an alleviation of the itching and burning, and 
reduces the temperature. In an ordinary case this is all 
that will be required. Hot drinks or stimulants have no 
power to hasten the appearance of the eruption ; the admin- 
istration of the latter may be followed by very injurious 
results ; convulsions may occur and death ensue. 

In an ordinary case, stimulants should never be adminis- 
tered during the initiatory period of the fever, unless there 
is some special indication for their use, such as great pros- 
tration, or bronchial complication ; then they may sometimes 
be used with benefit. Covering the patient with heavy 
clothing does not hasten the appearance of the eruption. 

The greatest cleanliness should be observed ; besides, 
there should be free ventilation, avoiding all draughts in 
the sick-room. If there is thirst, cold water may be freely 
taken in small quantities at a time. 

If the case is severe, and the temperature rises to 103° F. or 
104° F., it may be reduced by frequently sponging the sur- 
face with tepid or cold water. German writers recommend 
the cold bath in the treatment of measles. I should hesitate 
to place a patient with measles in a cold bath, on account 
of the great tendency in this disease to pulmonary complica- 
tions. 

Only a few days since I saw a child sick with measles, 
who had been treated with cold baths for the reduction of 
temperature. I found the physical evidences of extensive 
lobular pneumonias, which the attending physician said 
had been developed within the previous twenty-four hours, 
so that there was little doubt but that they were developed 
subsequent to the baths. 

My own experience leads me in the treatment of measles 
to employ quinine as an antipyretic, in preference to cold 
to the surface, either by baths or packs. 



352 MEASLES. 

You will recollect I stated that the post-pharyngeal 
catarrh is liable to extend into the larynx and bronchial 
tubes and give rise to bronchitis. One of the most impor- 
tant duties of the physician is to watch for the occurrence 
of this complication ; he should frequently examine the 
chest, and when the bronchitis is found to have reached the 
capillary tubes, should immediatly commence treatment for 
its relief. I have found the inhalation of steam to afford 
the greatest relief and best control the bronchial inflamma- 
tion. As soon as I find that the larynx has become so in- 
volved as to interfere with the respiration of the patient, 
and there is danger of croupous laryngitis, I immediately 
order vapor inhalations and insist upon their continuance 
until the laryngeal symptoms shall have subsided. Some- 
times this subsidence will take place within two or three 
hours, and, again, not until after two or three days. I de- 
sire to impress upon you the value of vapor inhalations in 
the treatment of the laryngeal and bronchial complications 
of measles. I have come to regard them as of great value. 

When catarrhal pneumonia is developed it is to be treated 
in the same manner as catarrhal pneumonia developed un- 
der any other circumstances ; the patient should be sustained 
by the free use of stimulants. 

Pulmonary complications in measles are often the result 
of exposure to sudden changes in temperature ; the severity 
of catarrhal symptoms will always be increased by such ex- 
posure, therefore it is of great importance in the manage- 
ment of a case of any type of measles that the patient should 
be protected against such exposure. 

When there is great restlessness during the fever of in- 
vasion, or during the early period of the eruptive stage, 
small doses of opium, in the form of Dover's powder, may 
be administered with marked benefit. 

The management of the different varieties of measles will 
be indicated by the general condition of the patient. In 
the ulcerative, hemorrhagic, and typhoid varieties, the free 
administration of stimulants should be early commenced. 
Usually in these varieties there is great prostration, and the 
thing to be accomplished is the support of your patient. 



GERMAN MEASLES. — MORBID ANATOMY. 353 

German Measles, or Epidemic Roseola. — Before leaving 
the subject of measles I will call your attention to an affec- 
tion wliich has recently received the name of German 
measles. It is commonly known by the term roseola, or 
mock measles. It has been regarded by some as a modified 
form of measles ; by others as a modified form of scarlet 
fever ; again it has been thought to be a combination of the 
two diseases. 

Some writers maintain that we are not justified in calling 
this type of measles an independent and specific disease, 
but that it may embrace any blotchy exanthemata, from the 
appearance of which we are unable to determine what we 
shall call the disease ; whether scarlet fever, or measles, or 
urticaria, etc. 

Later German writers regard it as an independent affec- 
tion, a specific, acute, and contagious eruptive fever, and 
have given to it the name of rubeola. 

I am disposed to regard it only as a different type of 
measles from that which ordinarily prevails, and by way of 
distinction will call it German measles, or epidemic roseola. 

Morbid Anatomy. — This affection must be regarded as 
one of the mildest of eruptive fevers. It has prevailed epi- 
demically and endemically. The study of its morbid anat- 
omy has been almost exclusively restricted to the eruption. 
This is an exanthemata consisting of irregular spots, or hy- 
persemic blotches, varying in size from a pin's head to a 
large pea, usually slightly elevated, so that when the hand 
passes over them the surface of the skin feels somewhat 
rough. Sometimes these spots occasion intense itching ; 
they are quite distinctly separated by healthy skin, and 
disappear under pressure. As a rule, even at the acme of 
the development of the eruption, their color is a ' ; pale rose 
red," paler than the intense red of the eruption of scarlet 
fever, or the peculiar bluish hue of the eruption in severe 
cases of measles. The eruption can readily be recognized. 
It is seen upon all parts of the body, but is most abundant 
upon the face and trunk. The spots are usually discrete ; 
they often lie crowded closely together, but they are not 
confluent. 

23 



i 



354 MEASLES. 

The eruption is exceedingly fugitive, rarely remaining 
visible more than twenty -four or forty-eight hours. It may 
continue visible for three or four days. The period of its 
most marked development may be only a few hours — twelve 
hours is the limit. In some cases there is slight desquama- 
tion ; in most cases the eruption disappears, and leaves no 
trace, except in occasional instances, when there is a tran- 
sient and yellowish discoloration of the skin. Some writers 
affirm that the eruption may disappear and reappear alter- 
nately for several days, and when it has finally disappeared 
the disease has terminated, and there is nothing to fear 
from complications or sequelse. In certain rare cases vesi- 
cles resembling miliaria may be developed upon the hyper- 
semic spots, especially upon the back ; doubtless these are 
chiefly due to external conditions. 

Etiology. — Doubtless this disease is a contagious affec- 
tion. Nothing is known concerning the nature of its con- 
tagion. It is essentially a disease of childhood. In persons 
more than forty years of age its development is of very rare 
occurrence. It is conveyed from one person to another in 
the same manner as measles. It has been thought by some 
that women were more susceptible than men to the influ- 
ence of the contagion, and that high atmospheric tempera- 
ture has a great influence in its development. 

Symptoms. — Epidemic roseola is so mild an affection, 
that it is questionable whether it has an invasive stage. 
The duration of the stage of incubation has not been deter- 
mined. Generally, the symptoms which manifest them- 
selves two or three days before the appearance of the erup- 
tion are much less marked than they are in any other 
eruptive fever. Perhaps in many cases they escape notice. 
Quite frequently the eruption is the first symptom of the 
disease. In some cases there may be nothing more than a 
feeling of discomfort. In other cases the disease may be 
ushered in by vomiting, diarrhoea, and convulsions. In 
many cases, immediately preceding the eruption, and 
accompanying its appearance, there is well-marked fever ? 
headache, loss of appetite, and sometimes noticeable pros- 
tration. When the eruption is regular in its appearance 



SYMPTOMS. 355 

it affects first the face and scalp, then gradually extends 
downward over the trunk and extremities. Usually, the 
development and speed of the eruption is rapid, perhaps 
no more than two or three days being occupied in its 
passage over the entire body. Its duration upon any one 
part of the body before it begins to disappear is not more 
than from twelve to twenty -four hours. Within forty-eight 
hours it has almost entirely disappeared. In the majority 
of cases the temperature does not rise more than 100i° F. 
to 101i° F. above the normal standard. It may rise from 
102° F. to 104 F.° During the second day of the disease 
the temperature begins to fall. Sometimes it reaches the 
normal standard within twelve hours, occasionally not 
until the third day. Sometimes it reaches it by crisis, at 
other times by gradual descent. 

The pulse increases and diminishes in frequency accord- 
ing to the rise and fall of temperature. 

The tongue is usually covered with a whitish coating, is 
dotted here and there with red and swollen papillae. The 
mucous membrane of the fauces is generally congested, and 
the tonsils moderately swollen ; there may be some soreness 
of the throat. 

The mucous membrane of the air-passages is usually 
in a condition of mild catarrh, consequently at the onset 
of the disease sneezing and coughing are frequently pres- 
ent, but they are less marked and are of shorter duration 
than in the ordinary type of true measles. 

Suffusion of the eyes with congestion of the conjunctival 
vessels is rarely present ; there may be a slight degree of 
photophobia. The face and eyelids are usually slightly 
swollen at the time the eruption makes its appearance, but 
this swelling rapidly disappears. 

In most cases, there is moderate swelling of the lymphatic 
glands of the neck, and enlargement of the glands at the 
nape of the neck. Moderate enlargement of the occipital 
glands may continue for a number of days. Suppuration 
of lymphatic glands has not been observed. The urine is 
usually normal ; it may, however, contain an abnormal 
amount of the chlorides. 



356 MEASLES. 

You have already learned the fact, that when this dis- 
ease runs its regular course, it is exceedingly mild in char- 
acter. So mild, that children generally dislike to remain 
in bed, and prefer to be out-of-doors and at play. 

Differential Diagnosis. — One of the prominent fea- 
tures of this disease is the close resemblance which its 
eruption bears to that of measles. In certain cases it may 
be impossible by the eruption alone to make a differential 
diagnosis. When the eruption of measles is not typically 
developed, a complete history of the case must be taken 
into consideration. When this has been done, usually 
there is no great difficulty in arriving at a correct diagnosis. 
Perhaps, that which will best aid you in making a dif- 
ferential diagnosis between roseola and measles is the fact 
that an attack of one does not protect against the other, 
any more than does an attack of varicella protect an indi- 
vidual from an attack of variola. This fact certainly 
establishes the non-identity of the two diseases. 

It has been questioned whether a person may not have a 
second attack of epidemic roseola. The latest observations 
go to prove that a second attack of roseola is of as rare 
occurrence as a second attack of measles or scarlet fever. 
Again, the evidence seems most conclusive that an attack 
of this disease does not protect an individual against the 
contagion of scarlet fever ; nor does an attack of scarlet 
fever protect one against the contagion of roseola. An in- 
dividual may have an attack of German measles very soon 
after he has been ill with measles or scarlet fever. 

Prognosis. — The prognosis is always good. Complica- 
tions rarely occur. When they do, they are usually pul- 
monary affections. 

Treatment. — The treatment of this affection simply con- 
sists in protection against exposure. Tepid sponging will 
relieve troublesome itching, and reduce fever. Regulate 
the diet, and carefully watch the catarrh of the air-pas- 
sages. In some cases, a mild course of tonic treatment 
may be beneficial. As a rule, convalescence is rapid, and 
is completed without hindrance. 



MORBID ANATOMY. 357 



MILIARY FEVER. 



This form of fever cannot strictly be regarded as a con- 
tagious disease, but it so frequently prevails in connection 
with measles and scarlet fever, and has apparently so many 
elements of contagion, that I have included it in the list of 
contagious fevers. 

Some deny its existence as a distinct fever. Writers have 
described it under the names of sudomina, sudoral exan- 
thema, miliaria alba, etc. I shall adopt the name of miliary 
fever. 

Several diseases which are accompanied by sweating, 
and which exhibit a tendency to the formation of miliary 
vesicles, have been called miliary fever. Until the occur- 
rence of the severe epidemic of the disease known as the 
" English Sweating Sickness," its specific type was not rec- 
ognized. It has prevailed epidemically over limited areas, 
in Belgium, France, England, Germany, Italy, and Austria. 

In some of these epidemics one-fifth to one-tenth per cent, 
of the whole population of the invaded district has been at- 
tacked by the disease. The average duration of the epi- 
demics has been from three to four weeks, occasionally they 
have lasted from three to four months. 

Morbid Anatomy. — Few post-mortem examinations have 
been made, and those few have failed to reveal any charac- 
teristic lesion. 

During life the blood is thin, of a bright-red color, and 
coagulates imperfectly ; after death it is thin and dark- 
colored. 

Generally, the internal organs present evidences of hyper- 
emia. The mucous membrane of the air-passages is red 
and frequently covered with reddish mucus. The lungs 
and liver are generally filled with blood ; the latter is softer 
than normal. The spleen is always enlarged and soft. 
Some observers have reported the kidneys to be in a normal 
condition ; other observers have reported them to be in a 
condition of congestion. The mucous membrane of the 
stomach and intestines is usually reddened, and presents 
here and there red spots. Occasionally these spots are very 



358 MILIAEY FEVEE. 

numerous, and vesicles are sometimes seen in the small in- 
testines. By some these vesicles have been supposed to be 
swollen, solitary follicles ; by others they have been thought 
to be distinct miliary vesicles, similar to those which are 
seen upon the surface of the body. Superficial ulcers are 
sometimes seen, especially in the region of the ilio-csecal 
valve. 

The miliary vesicles which are seen upon the surface 
of the body, and the cutaneous eruption, are developed 
because the secretion of the sudoriferous glands cannot 
escape. 

The escape of the contents of these glands may not 
take place for two reasons : First, the gland-ducts may 
become obstructed. Second, the secretion may be so abun- 
dant that it cannot be transmitted by the gland-duct. 

In either case, the secretion emerges under the epidermis 
around the sweat-duct, and, as the scales are lifted up, a 
small clear vesicle is formed. The liquid contained in the 
vesicle at first is transparent, has an acid reaction, and is 
said to contain free nuclei-cells, which have three or more 
nuclei ; these nuclei remain visible after the cell membrane 
has been destroyed by the addition of acetic acid. 

It has been claimed that the virus of the disease is con- 
tained in these polynucleated cells. After death, the skin 
becomes oedematous, and very soon the odor of decomposi- 
tion is perceivable. 

Etiology. — It was formerly supposed that miliary fever 
was indirectly induced by scarlatina, the puerperal con- 
dition, variola, vaccinia, typhus fever, and other diseases, 
and that it was not a distinct disease arising from some 
constitutional cause. The prevalence of this fever in con- 
nection with these diseases gave rise to this supposition. 

Epidemics of this disease have generally prevailed during 
the spring and summer months ; from this fact one would 
be led to think that there is some atmospheric condition 
peculiar to these months. Again, the disease has most fre- 
quently appeared in warm, moist weather, and from this 
fact it has been supposed that some peculiar condition of 
the soil is necessary to its development. Certain epidemics 



ETIOLOGY. 359 

have shown a close connection with contaminations of the 
soil, snch as arise from neglect of drainage, collections of 
refnse, etc. Doubtless, such conditions of the soil may in- 
crease its severity, and cause it to prevail more extensively, 
but facts do not prove that, directly or indirectly, they 
cause its development. 

The disease usually attacks healthy adults, and occurs 
more frequently among females than males. It attacks all 
classes, and its spread does not seem to be affected by 
crowding. 

It can hardly be regarded as a contagious disease, in the 
sense that it can be communicated directly from the sick to 
the well. It does not seem to be well established that the 
disease can be developed by inoculation with the contents 
of the vesicle, notwithstanding it has been supposed that 
certain cells in the fluid hold the contagion of the disease. 

The inf requenc}^ of the simultaneous occurrence of miliary 
fever, with epidemics of measles or scarlet fever, is unfavor- 
able to the theory that there is a specific relationship be- 
tween the poisons of these diseases. 

The view that there is an intimate relationship between 
cholera and miliary fever has been accepted by some wri- 
ters, and the accession of the latter during the course of 
the former has been supposed to exert a favorable influence 
over the course of the disease ; the opposite, however, does 
not appear to hold good, but, on the contrary, favors a 
fatal termination. Much remains to be learned in regard 
to the relationship existing between miliary fever and the 
other diseases which we have mentioned. 

The etiology seems to be mainly speculative and theo- 
retical. 

Symptoms. — The average duration of the disease is from 
five to eight days. 

It has three stages : First, the stage of invasion ; second, 
the stage of sweating ; third, the stage of eruption and des- 
quamation. 

The stage of invasion. — The average duration of this 
stage is from forty-eight to seventy-two hours. It is char- 
acterized by an excessive irritation of the skin, thirst, gen- 



360 MILIARY FEVER. 

eral lassitude and headache. There is also more or less 
febrile movement. 

Some writers mention a feeling of suffocation, which is 
usually preceded by a sense of oppression at the epigas- 
trium. These are the characteristic symptoms of the stage 
of invasion. 

The stage of sweating. — This stage is usually ushered in 
by rigors ; rarely, by a well-marked chill. The character- 
istic symptom of this stage is profuse and persistent sweat- 
ing. The sweating is accompanied by a prickling sensation 
of the skin, distress, and a sense of compression at the epi- 
gastrium, by more or less violent palpitation of the heart, 
with precordial pain. Usually the sweat appears on all 
parts of the body at the same time. Sometimes it appears 
first upon the head and breast, then gradually descends, 
and soon becomes so abundant that every article of cloth- 
ing, bed-clothes, and bedding, becomes saturated. 

The pulse sometimes reaches 140 beats per minute, the 
temperature rises to 103° F., 104° F., or 105° F., and the 
skin, notwithstanding the profuse perspiration, feels ex- 
tremely hot. 

During this stage the headache and the sense of suffoca- 
tion increase, the epigastric and precordial pain, and the 
palpitation increase in severity, and sometimes become 
alarming, although the most careful physical examination 
fails to discover any lesion in the heart or lungs to account 
for them. The respiration becomes rapid, often irregular 
and intermittent. Irregular exacerbations, or even inter- 
missions, in these symptoms may occur, but, as a rule, they 
continue without abatement until the vesicle appears on 
the third or fourth day of the disease. 

The Stage of Eruption. — This stage is characterized 
by the appearance of a rash. It is first seen upon the neck 
and breast, then upon the back and extremities, sometimes 
upon the mucous membrane of the mouth, nose, and con- 
junctiva, sometimes upon the abdomen and scalp. This erup- 
tion consists of irregularly shaped spots, three or four mm. 
in diameter. In some cases they stud the skin so thickly 
that it appears like an uniform sheet of vivid redness, 



SYMPTOMS. 361 

After the lapse of a few hours, vesicles can be seen in the 
centre of these spots ; perhaps, at first, they are so small as 
to necessitate the aid of a lens to discover them. These 
vesicles rapidly increase in size, and may reach the size of a 
millet-seed or a small pea. The contents of these vesicles 
have already been described. 

Occasionally, as the eruption appears, all the constitu- 
tional symptoms are increased in severity, but, usually, they 
are modified and disappear either suddenly or gradually 
after its development. In the milder cases the vesicles 
only, without the efflorescence, are seen. 

Vomiting is rarely present, although nausea is a com- 
mon symptom, as is also constipation. The urine is usually 
scanty and high colored ; in some cases there is suppression 
of urine. Occasionally, during the stage of eruption, pro- 
fuse secretion of urine takes place. This has been regarded 
as a favorable symptom. 

The vesicles, clear at first, soon become opaque and yel- 
lowish, continue for two or three days, then burst and begin 
to fall off in scales. Desquamation is usually completed 
within forty-eight hours, but convalescence is often quite 
protracted on account of the debility and emaciation. 
Such is a brief description of miliary fever, when it runs a 
regular course, but there are certain variations in the de- 
velopment of the symptoms which should be noticed. In 
the severest form of the disease, the temperature may rise 
to 107° or 108° F., and there may be a sense of suffocation and 
raging delirium. Again, there may be absence of the erup- 
tion, sweating, and convulsions followed by death. Occasion- 
ally sudden and fatal collapse follows the sweating stage. 

The typhoid condition may be developed in the sweating 
stage, and may be attended by black sordes upon the teeth 
and tongue, epistaxis and uterine hemorrhage, and may 
terminate in death, without any considerable anatomical 
changes recognizable after death. 

Complications are not of frequent occurrence. Occasion- 
ally there is bronchitis, pneumonia, and angina. 

Relapses are of common occurrence, but recovery gener- 
ally takes place after a short relapse. 



362 MILIAEY FEVER. 

Differential Diagnosis. — Miliary fever may be con- 
founded with measles, with typhoid fever, and with dengue 
fever. The profuse sweating, the prickling of the skin, the 
intense oppression at the epigastrium, the sense of suffoca- 
tion, with precordial pain, and the peculiarity of the erup- 
tion, are sufficient to distinguish it from measles, from 
intermittent fever (although a decidedly intermittent type 
of the disease sometimes prevails), and from typhoid fever. 
When the disease prevails epidemically, the diagnosis 
cannot be difficult. 

Prognosis. — When the disease runs a regular course, 
with only a moderate degree of severity, the prognosis 
is good ; whereas, great severity of the febrile symptoms, 
exceptionally profuse sweating, and increasing sense of con- 
striction of the chest, with suffocation, render the prognosis 
unfavorable. The accession of profuse hemorrhages, coma, 
convulsions, active delirium, or symptoms of collapse, ren- 
der the prognosis unfavorable. 

The severity of the symptoms is usually mitigated when 
the eruption makes its appearance, and death rarely occurs 
after that stage is reached. If fatal termination is reached, 
it usually takes place during an exacerbation, prior to the 
appearance of the eruption. 

In some epidemics, the mortality has been very great ; in 
other epidemics the disease has been mild in character. 
The character of the epidemic affects the prognosis. 
Treatment. — At one time diaphoretics were employed 
in the treatment of this disease, on the supposition that 
the sweating and eruption were critical manifestations, and 
must be aided by all possible means. 

The sense of suffocation, with that of constriction of the 
chest, was thought to indicate blood-letting ; but it was 
soon decided that loss of blood aggravated rather than im- 
proved the patient's condition. 

Antispasmodics, nervines, quinine, emetics, and counter- 
irritants, at different times have formed the basis of various 
plans of treatment. Of late, subcutaneous injections of 
morphine have been used with advantage. Sinapisms and 
blisters have been employed for the relief of the sense of 



TREATMENT. 363 

constriction in the chest, and for the epigastric and precor- 
dial distress, with benefit to the patient. 

It is now acknowledged that the administration of purga- 
tives in large doses should be carefully avoided, as well as 
bloodletting, general or local. 

At present the expectant plan of treatment is regarded 
with most favor. It chiefly consists in the use of cooling 
drinks, aromatic teas, acidulated water, sponging with 
warm water, or the employment of warm baths. It has 
been thought that the addition of alum or vinegar to the 
water used for sponging or bathing is beneficial. 

In the treatment of this affection, quinine seems to be 
regarded with almost universal favor. If restlessness is 
persistent, opium, ether, and antispasmodics may be em- 
ployed in moderate doses, carefully watching the effect 
produced. The patient should be surrounded by proper 
hygienic influences, his diet should be moderately nutritive, 
and, in those cases in which convalescence is tedious, a 
steady and continued tonic treatment is indicated. 

In the severest form of the disease stimulants may be 
employed with benefit. 



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Steiner, Johann. Compendium der Kinderkrankheiten. Leipzig, 1872. 

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Stokes, Dr. William. Lectures on the Theory and Practice of- Physic. Phila- 
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Sutton, Dr. W. L. A History of the Disease usually called Typhoid Fever, 
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INDEX. 



PAGE 

Algid variety of pernicious fever 157, 158 

Alkalies in the treatment of typhoid fever 77 

Antipyretics in the treatment of simple remittent fever 146-148 

" " " typhoid fever 66-73 

li " " typho-malarial fever 198-200 

Arrangement of sick-room in the treatment of measles , 351 

" " " simple remittent fever 146 

" " " typhoid fever 64 

" " " typhus fever 347 

Arthritic pains in relapsing fever 261 

Astringents in the treatment of typhoid fever 77 

Bibliography 365-384 

Bilious remittent fever 141 

Black vomit as a symptom of yellow fever 96 

Blood, changes in the, in measles 337 

" " miliary fever. . . 357 

44 " pernicious fever 149 

" " relapsing fever 258 

" " simple remittent fever 132 

" " typhoid fever 7,8 

" " typho-malarial fever 182 

" " typhus fever 206 

" " yeUow fever 88 

Bloodletting in pernicious fever 164 

44 typhoid fever 63 

Brain, changes in the, in pernicious fever 151 

" " scarlet fever _ 308 

" " typhoid fever ' 12 

" " typhusfever 207,208 

" " yellow fever ' 87 

Bronzed liver in simple remittent fever 133 

Cathartics in the treatment of dengue fever 173 

" " pernicious fever , 164 

" " typhoid fever 81 



386 index. 



PAGE 

Chronic malarial infection 173-180 

" " definition of 173 

" " differential diagnosis of 177 

" " etiologyof 174 

11 " morbid anatomy of 174 

" " " " heart 174 

" " " " liver „ 174 

" " " " kidneys 174 

" " " " spleen 174 

" " prognosis of 178 

" " symptoms of 174-177 

" " " diarrhoea 175 

" u " gastro- enteritis 175 

" " " hemiplegia 175 

" " " hemorrhage 176 

" " " hypochondriasis 176 

" " " local anaesthesia 175 

" " " melancholia 176 

" " '' neuralgia '.. 176 

" " treatment of 179,180 

Citrate of iron and quinine in the treatment of dengue fever 173 

Cod-liyer oil " " chronic malarial infection . . 179 

Colchicum " " dengue fever 172 

Cold applications " " measles 351 

" " " scarlet fever. 332 

" " " simple remittent fever 148 

" ".'..." typhoid fever.. . . . 67-70 

" " " typho-malarial fever 201 

u " " typhus fever ...249 

Collapse in pernicious fever 156 

Colliquative variety of pernicious fever 158 

Coma vigil in typhus fever 220 

Comatose variety of pernicious fever 153 

Contagion in measles 339 

" relapsing fever , 260 

" scarlet fever , 308 

" small-pox 273 

" typhoid fever 21 

" typhus fever 212-214 

" yellow fever 90-92 

Convulsions in pernicious fever 155 

" scarlet fever 315 

" typhoid fever 37 

Delirious variety of pernicious fever 154, 155 

Delirium in pernicious fever 154 

" relapsing fever ' 261 

u scarlet fever. 312 



INDEX. 



387 



Delirium in small-pox 276 

typhoid fever , 35-86 

typho-malarial fever 192 

typhus fever , 220-222 

yellow fever 98 

Dengue fever 169-173 

etiology of 169-170 

definition of 169 

differential diagnosis of 172 

morbid anatomy of 169 

prognosis of 172 

symptoms of 170-172 

u enlargement of lymphatic glands 170 

" headache 170 

" period of incubation 170 

" pulse 170 

" skin 170 

' ' temperature 170 

" tongue 171 

treatment of 172, 173 

" calomel in the 172 

cathartics in the 173 

' ' citrate of iron and quinine in the 173 

" colchicum in the 172 

" diet in the 173 

' ' emetics in the 173 

4 ' sulphate of quinine in the 173 

Diaphoretics in the treatment of typhoid fever 63 

Diarrhoea in chronic malarial infection 175 

" relapsing fever 261 

" typhoid fever 31 

" typho-malarial fever 188-191 

Diet in dengue fever 173 

'' measles 351 

" typhoid fever 75 

" typho-malarial fever 202 

" typhus fever 254 

Differential diagnosis of chronic malarial infection 177 

" *' dengue fever 172 

u " epidemic roseola 354 

u " measles 348 

w " miliary fever 362 

" " pernicious fever 159-162 

" a relapsing fever 264 

" " scarlet fever 326-328 

" " simple intermittent fever 125 

" ". simple remittent fever 142, 143 

" " small-pox.... 284-286 



388 INDEX. 

PAGE 

Differential diagnosis of typhoid fever 45-49 

" " typho-malarial fever 194-196 

" " typhus fever 232-239 

" " yeUow fever 100 

Digitalis in the treatment of typhus fever „ 253 

Disinfectants in the treatment of typhoid fever 62 

Dry cups u " " 79 

Emaciation in typhoid fever ...... 38 

Emetics in the treatment of dengue fever 172 

" " pernicious fever 164 

" " typhoid fever 63 

Epidemic roseola 353-356 

" differential diagnosis of 354 

" etiology of 354 

" morbid anatomy of 353 

" prognosis of 355 

" symptoms of 355, 356 

" treatment of 356 

Epistaxis as a symptom of typhoid fever „ 170 

Eruption of dengue fever 169-171 

" epidemic roseola 353 

" measles. 341 

" miliary fever 358-360 

' ' relapsing fever 262 

" scarlet fever 313 

small-pox 270-273,277-284 

" typhoid fever 42-43 

" typhus fever 219-225 

Etiology of chronic malarial infection 174 

" dengue fever 169, 170 

" epidemic roseola 354 

" measles 339-341 

" miliary fever . . . . 358, 359 

" pernicious fever 152 

" relapsing fever 258-260 

" scarlet fever 308-311 

' ' simple intermittent fever 120 

" " remittent fever 134-136 

" small-pox 273-275 

" typhoid fever 20-26 

" typho -malarial fever 186 

" typhus fever 211-216 

" yellow fever . . • • 88-93 

Fevers, classification of 5-7 

• ' contagious 5 

" dengue 169-173 



INDEX. 389 

PAGE 

Fevers, endemic • . 5 

epidemic .5 

introduction to 1-5 

malarial 109 

measles 337-356 

miasmatic contagious 5 

miliary 357-363 

pernicious 148-168 

relapsing 256-267 

scarlet 304-336 

simple intermittent 119-144 

" remittent 138-148 

small-pox 268-302 

typhoid 7-84 

typho-malarial 181-202 

typhus 205-255 

yellow 85-107 

Fresh air in the treatment of typhus fever 247 

Gangrene of tonsils in scarlet fever 306 

Gastro-enteric variety of pernicious fever 155, 156 

Gastro-enteritis in chronic malarial infection 175 

German measles 353-356 

Glandular enlargements in typhus fever 210 

Glandular inflammation in scarlet fever 306 

Headache in dengue fever 170 

" miliary fever 360 

" pernicious fever 154 

' ' scarlet fever 315 

" typhoid fever 35 

" typhus fever 217, 222 

Heart, changes in the, in chronic malarial infection 174 

" relapsing fever 258 

" typhoid fever ... 9, 10 

" typho-malarial fever 183 

" typhus fever 207 

" yellow fever 86,87 

Hemiplegia in chronic malarial infection 175 

Hemorrhage in chronic malarial infection 176 

" pernicious fever 158 

" typhoid fever, from intestines 31, 32 

" " larynx 12 

" typho-malarial fever 193 

Hydrate of chloral in typhoid f ev«er 82 

' k typhus fever 253 

Hyperesthesia in typhoid fever 37 

Hypochondriasis in chronic malarial infection 176 



390 INDEX. 

PAGE 

Hypodermic injections of opium in pernicious fever 164-165 

" " sulphate of quinine in pernicious fever 164-165 

Icteric variety of pernicious fever 158-159 



Infarctions in the kidneys in typhoid fever 99 

" " lungs in yellow fever 87 

" " spleen in pernicious fever 151 

Inoculation 293-295 

Intestines, lesions of the, in relapsing- fever 257 

" " simple remittent fever 134 

." " typhoid fever 14-18 

" typho-malarial fever. .. . 183-185 

typhus fever 208 

Intestinal hemorrhage in typhoid fever 31, 32 

Iodide of iron in chronic malarial infection 179 

Iron cough in measles 342 

Jaundice in bilious remittent fever . 141 

" pernicious fever 158-159 

" relapsing fever 261 

" yellow fever 98 

Kidneys, changes in the, in chronic malarial infection 174 

" u pernicious fever 152 

relapsing fever 257 

scarlet fever 307 

typhoid fever 9 

typho-malarial fever 183 

typhus fever 207 

yellow fever 87 

Laryngitis, in typhoid fever 11 

" typhus fever 230 

Liver, changes in the, in chronic malarial infection , . 174 

" " measles 337 

" " pernicious fever 151 

lt " relapsing fever 257 

" " scarlet fever 308 

" " simple remittent fever 133 

" " typhoid fever 8-9 

" " typho-malarial fever 182 

" " typhus fever 206 

" " yellow fever 85,86 

Lungs, changes in the, in pernicious fever 152 

" " measles 338 

" " typhoid fever 10,11 

" " typho-malarial fever 183 



INDEX. 391 

PAGE 

Lungs, changes in the, in typhus fever 207 

" " yellow fever 87 

Lymphatic glands, enlargement of, in dengue fever 170 

Malarial fevers, introduction to 109-118 

Masked intermittent fever 130 

Measles .337-356 

' ' complications of 346 

" differential diagnosis of 348 

' ' etiology of 339-341 

" morbid anatomy of 337-339 

" " bloodchanges 337 

" '" eruption 338 

" " liver 337 

" " lungs 338 

" " skin 338 

" " spleen 337 

" period of incubation 340 

'■' prognosis of 349 

" symptoms of , 341-348 

" " desquamation 342 

" " eruption 341 

^ " iron cough 342 

11 4i irregularities . 343 

" " premonitory 341 

" " pulse , 343,344 

" " temperature 343,344 

" " tongue 344 

" treatment of 350. 352 

" " arrangement of sick-room , 351 

" " cold applications 351 

" " diet 351 

" " opium 352 

" " sponging 351 

" " stimulants 351,352 

" " sulphate of quinine 351 

" " vapor inhalations 352 

u " ventilation 351 

Melancholia in chronic malarial infection 176 

Meningitis in typhus fever 230 

Mercury in the treatment of dengue fever 172 

" " simple remittent fever 146 

" " typho-malarial fever 201 

Mesenteric glands, changes in the, in typhoid fever. . . , 18-20 

" " " typho-malarial fever 185 

Miliary fever 357-363 

" " complications of 362 

" " differential diagnosis of 362 



392 INDEX. 

PAGE 

Miliary fever, duration of ; 359 

" etiology of 358, 359 

" " morbid anatomy of 357, 358 

" " prognosis of 362 

" " relapses in 361 

" " symptoms of 359-362 

" " " desquamation 362 

" " " eruption 360 

" " " headache 360 

" " " pain, epigastric 360 

" " " " precordial 360 

". " " pulse 360 

" " " rapid respiration 360 

" " " stages 359 

" " " temperature . 360 

" " urine 361 

" " " vomiting 361 

u " treatment of 362, 363 

Morbid anatomy of, chronic malarial infection 174 

" " dengue fever 169 

" " epidemic roseola 353 

" measles 337-339 

" " miliary fever 357 

" " pernicious fever 149-152 

" " relapsing fever 256-258 

" " scarletfever 305-308 

" " simple intermittent fever 119 

" " simple remittent fever 132-134 

" small-pox... 269-273 

" " typhoid fever 7-21 

" " typho-malarial fever 182-186 

" " typhus fever 205-211 

" " yellow fever 85-88 

Morphine, hypodermic injections of, in pernicious fever 164, 165 

" " " simple remittent fever 148 

u " " typhoid fever .. 79 

Mucous membrane, changes in the, in relapsing fever 287 

*• " " scarlet fever 306 

" " " yellow fever 86 

Muscles, changes in the, in simple remittent fever 134 

" " " typhoid fever 12, 13 

" " " typhus fever 211 

" paralysis of, in typhoid fever 36 

" " typhus fever 223 

Neuralgia, in chronic malarial infection 178 

Opium in the treatment of measles 851 



INDEX. 393 

PAGE 

Opium in the treatment of pernicious fever 164 

" " simple remittent fever 127 

" " typhoid fever 77-79, 82 

" " typho-malarial fever 200 

11 " typhus fever t 253 

Pain in the epigastrium in simple remittent fever 137 

Parenchymatous degenerations in typhus fever 206 

Period of incubation in dengue fever 170 

" " measles 340 

" " scarlet fever 311 

" " small-pox 275 

" " typhus fever 215 

Pernicious fever 148-1 68 

" definition of 152 

" differential diagnosis of 159-162 

' ' etiology of 152 

" morbid anatomy of 1 49-152 

blood changes 149 

brain 151 

kidneys , 152 

liver 151 

lungs 152 

spinal cord 151 

spleen .. . 151 

prognosis of 162, 163 

" symptoms of 152-159 

" " algid variety. 157, 158 

" " colliquative variety 158 

" " comatose " 153 

" " delirioas " 154, 155 

" " gastroenteric " 155, 156 

" " icteric " . 158-159 

" " premonitory 152 

" treatment of 163-168 

" «' bleeding 164 

" u cathartics 164 

" " depletion 164 

" treatment of, emetics 164, 169 

" " hypodermic injections of opium and quin- 
ine 164-165 

" " opium 164 

" " stimulants 167 

" " sulphate of quinine 164 

" " Warberg's tincture 166 

" varieties of 149 

Phlegmasia dolens in typhus fever 210 

Phosphorus " " 253 



394 INDEX. 

PAGE 

Photophobia in relapsing fever 8 261 

Physiognomy in dengue fever 170 

' ' pernicious fever 158 

" small-pox 276 

" typhoid fever 29, 30 

Premonitory symptoms in measles 341 

" pernicious fever 152 

" scarlet fever 311-312 

' ' simple remittent 136 

" small pox 275 

" typhoid fever 27 

" typho-malarial fever 187 

" typhus fever 217 

" yellow fever 93 

Prognosis in chronic malarial infection 178 

" dengue fever 172 

" epidemic roseola 355 

" measles 349 

" miliary fever 362 

" pernicious fever 162, 163 

" relapsing fever 265 

" scarlet fever 328-330 

" simple intermittent fever 126 

" simple remittent fever 143-144 

" small-pox 286-288 

u typhoid fever 50-60 

" typho-malarial fever .196-198 

" typhus fever , 239-243 

" yellow fever 102 

Pulse in dengue fever 170 

" measles .343-344 

" miliary fever 368 

" pernicious fever •. . .153-159 

u relapsing fever 261 

" scarlet fever 311, 316 

" simple remittent fever 137 

" small-pox 276 

" typhoid fever 40-42 

" typho-malarial fever 189-191 

" typhus fever 219-223 

" yellow fever 95 

Relapses in miliary fever 362 

" relapsing fever .• 262 

typhoid fever 58-60 

' ' typhus fever 232 

Relapsing fever 256-267 

" complications of 264 



INDEX. 



395 



Eespirat 



fever, differential diagnosis of 264 

etiology of 258-260 

morbid anatomy of 256-258 

" blood 258 

" hearb 258 

u intestines 257 

" kidneys 257 

liver 257 

' ' mucous membrane 257 

" spleen 256 

prognosis of ; .... 265 

symptoms of 260-264 

' ' arthritic pains 261 

" delirium 261 

" diarrhoea 261 

" eruption 261 

" jaundice 261 

" photophobia 261 

pulse , 261 

" temperature 261 

' ' vomiting 261 

treatment of 266 

on in typhus fever 226 



Salivary glands, changes in the, in typhoid fever IB 

Scarlet fever 304-336 

u complications of 321 

" definition of 304 

" differential diagnosis of 326-328 

" etiology of 308-311 

" morbid anatomy of 305-308 

" " brain 308 

" " diphtheria 307 

ear 307 

gangrene of tonsils 306 

glandular inflammation 306 

kidneys.... 307 

liver 308 

" mucous membranes 306 

" skin 305 

period of incubation 311 

periods of 304 

prognosis of 328-330 

sequelae 323-325 

symptoms of 311-326 

convulsions 315 

" delirium 312 

" eruption 313 



(( 


a 


t( 


tc 


a 


u 


u 


a 


<( 


u 



396 



INDEX. 



Scarlet fever, symptoms of, headache 315 

" " premonitory 311, 312 

" " pulse 311,316 

" " stages 312 

" " temperature 311,316 

" " tongue 312 

" " urine 312 

" " vomiting 311 

" treatment of 330-336 

Sewer gas, as a cause of typho-malarial fever 13 

Sight, as a symptom in typhoid fever 37 

Simple intermittent fever 11 9-144 

etiology of . „ 120 

differential diagnosis of 125 

morbid anatomy of 119 

prognosis of . . . . , 126 

symptoms of 120-125 

" nausea 123 

" skin 122 

" temperature 122, 124 

" tongue 123 

urine 122, 123 

" vomiting 123 

treatment of 126-130 

iron 130 

" opium. 127 

" sulphate of quinine 128 

a stimulants 130 

Simple remittent fever 132-148 

" differential diagnosis of 142-143 

" etiologyof .. 134-136 

' ' morbid anatomy of 132-134 

" " blood changes , 132 

" " intestines 134 

" " liver 133 

" " muscles 134 

" " spleen 133 

" " stomach 134 

" prognosis of 143, 144 

" symptoms of 136-142 

" " pain in epigastrium 137 

" " premonitory 136 

" pulse 137 

" " temperature 137 

" " vomiting 137,138 

" treatment of 145-148 

" " antiphlogistics 145 

" u antipyretics 146-148 



INDEX, 



397 



PAGE 

Simple remittent fever, treatment of, arrangement of sick-room 146 

" " cold 148 

" " mercnry 146 

" " morphine 148 

" " sulphate of quinine . 146 

Skin, appearance of, in dengue fever 169-170 

" measles 338 

" miliary fever 360 

pernicious fever 153-157 

" relapsing fever 261 

" scarlet fever 305 

simple intermittent fever 122 

" simple remittent fever 141 

" small-pox 277-284 

" typhoid fever 42, 43 

" typho-malarial fever 191 

" typhus fever 219-225 

' ' yellow fever 88 

Small-pox 268-302 

" complications of 302 

" differential diagnosis of 284-286 

" eruption of 270-273 

" etiology of 273-275 

" inoculation in 293-295 

" morbid anatomy of 269-273 

" period of incubation of 275 

" prognosis of 286-288 

" symptoms of 275-284 

convulsions 276 

delirium 276 

eruption 277-284 

pain in the back and head 276 

physiognomy 275 

premonitory 275 

pulse 276 

skin 277-284 

temperature 275 

vomiting 276 

treatment of 289-292 

" vaccination 295-300 

Somnolence in typhoid fever 35 

" typhus fever „ 222 

Spleen, changes in the, in chronic malarial infection 174 

" measles 337 

" pernicious fever 151 

" relapsing fever 256 

simple remittent fever 133 

" typhoid fever 8 



398 



INDEX. 



Spleen, changes in the, in typho-malarial fever 183 

" typhus fever 206 

" yellow fever 88 

Spontaneous origin of typhoid fever 21 

Stimulants in measles. 352 

" pernicious fever 167 

" typhoid fever 73, 74 

' ' typho-malarial fever 200 

" typhus fever 250-252 

Stomach, changes in the, in simple remittent fever 134 

" typhoid fever 12 

Sulphate of quinine in chronic malarial infection 180 

" " " dengue fever 173 

u " " measles 351 

" u " pernicious fever 164,165 

" " " simple intermittent fever 128 

" " " simple remittent fever 146 

" " " typhoid fever 71-73 

" " " typho-malarial fever 198, 199 

11 " " typhus fever. ...248 

Suppression of urine in yellow fever 97 

Symptoms of, chronic malarial infection , 174-177 

" dengue fever 170-172 

* ' epidemic roseola 355, 356 

" measles 341-348 

" miliary fever 359-362 

M pernicious fever 152-159 

" relapsing fever. 260-264 

scarlet fever 31 1-326 

" simple intermittent fever 120-125 

" simple remittent fever 136-142 

" small-pox 275-284 

" typhoid fever 27-45 

" typho-malarial fever 187-194 

" typhus fever 217-229 

" yellow fever 93-100 



Tetanus in pernicious fever 155 

Temperature in dengue fever 170 

measles 343 

miliary fever 360 

pernicious fever, algid variety 157 

' ' colliquative variety 158 



comatose 
delirious 
gastro-enteric 
icteric 



relapsing fever. 



153 
155 
156 
159 
261 



index. 399 

PAGE 

Temperature in scarlet fever 311, 316 

" simple intermittent fever 122, 124 

" simple remittent fever 137 

" small-pox 275 

" typhoid fever 39, 40 

" typho-malarial fever 188, 190 

" typhus fever 318, 223 

" yellow fever 93-94 

Tents in the treatment of typhus fever 247 

Thrombi in the heart in typhoid fever 10 

veins in typhoid fever 207 

Tongue, appearance of, in dengue fever 171 

u " measles 344 

" " pernicious fever 157 

" " scarlet fever 312 

" " simple intermittent fever 123 

" " typhoid fever 30 

" " typho-malarial fever 188, 191 

" " typhus fever 218 

" " yellow fever 96 

Tracheotomy in the treatment of typhoid fever 80 

Treatment of chronic malarial infection 179, 180 

" dengue fever 172-173 

u epidemic roseola 356 

" measles 350-352 

" miliary fever 362, 363 

" pernicious fever 163-168 

" relapsing fever 266 

11 scarlet fever 330-336 

" simple intermittent fever 126-130 

" simple remittent fever 145-148 

" small-pox 289-292 

" typhoid fever 61-84 

" typho malarial fever 189-202 

" typhus fever 243-255 

" yellow fever 103-106 

Turpentine in the treatment of typhoid fever 78 

" " " typho-malarial fever 201 

Tympanitis in typhoid fever 33 

Typhoid fever 7-84 

" differential diagnosis of . .45-49 

" duration of 58 

" etiology of 20-26 

" morbid anatomy of 7-20 

" " blood changes 7,8 

" " brain and nervous system 12 

" " bronchial tubes 11 

" " heart 9,10 



400 



INDEX. 



Typhoid fever, morbid anatomy of kidneys 9 

larynx 11, 12 

liver ..8,9 

lungs 10, 11 

intestines 14-18 

mesenteric glands 18-20 

muscles 12, 13 

salivary glands 13 

spleen 8 

stomach 12 

symptoms of 27-45 

" abdominal pain .32, 33 

" convulsions 37 

" delirium 35, 36 

" diarrhoea 31 

' ' emaciation 38 

" epistaxis 37-38 

" eruption 42-43 

" headache 35 

' ' hearing 37 

" hyperesthesia 37 

" intestinal hemorrhage 31-32 

" muscular paralysis. 36 

1 ' physiognomy 29, 30 

" pulse 40-42 

sight 37 

" somnolence 35 

" taste 37 

" temperature .39-40 

" tongue 30 

" tympanitis 33 

" urine 34 

prognosis of 50-60 

relapses in 58-60 

treatment of 61-84 

" alkalies 77 

" antipyretics 66-73 

" arrangement of the sick-room 64 

" astringents 77 

" blood-letting 63 

" cathartics 81 

" cold applications 67-70 

' ' diaphoretics 63 

" diet 75 

" disinfectants 62 

" dry cups 79 

" emetics 63 

" hydrate of chloral 82 



I^DEX. 401 

PAGE 

Typhoid fever, treatment of, morphine 79 

opium 77-82 

' - " " stimulants 73, 74 

" " sulphate of quinine 71-73 

" " tracheotomy 80 

te " turpentine 78 

" " vapor inhalations . 79 

Typho-malarial fever . 181-202 

" definition of 181 

" differential diagnosis of 194-196 

" duration of 189 

" etiology of 186 

" morbid anatomy of , . . 182-186 

" " blood changes 182 

" " heart 183 

" " intestines 183-185 

" " kidneys 183 

" liver.. 182 

" " lungs 183 

" " mesenteric glands 185 

" " spleen 183 

" prognosis of 196-198 

" symptoms of 187-194 

" " abdomen 192 

" " delirium 192 

" " diarrhoea 188-191 

" " headache 192 

" premonitory 187 

" " pulse 189,191 

u " skin 191 

" " temperature 188, 190 

" " tongue 188,191 

" " urine 191 

treatment of 198-202 

" " calomel 201 

" cold applications 201 

" " diet 202 

opium 200 

" " stimulants 200 

l * " sulphate of quinine. 198 

" " turpentine 201 

Typhus fever 205-255 

" differential diagnosis of 232-239 

' ' duration of 232 

" etiology of 211-216 

" morbid anatomy of 205-211 

blood changes 206 

brain 207-208 



402 



INDEX. 



PAGE 

Typhus fever, morbid anatomy of bronchi , 209 

glandular enlargements 210 

heart 207 

intestines 208 

kidneys 207 

liver , 206 

lungs 207 

muscles 211 

parenchymatous degenerations 206 

phlegmasia dolens 210 

• spleen 206 

thrombi 207 

prognosis of 239-243 

symptoms of 217-229 

bronchitis 230 

coma vigil 220 

delirium 220, 222 

eruption 219, 225 

headache 217, 222 

laryngitis , 230 

meningitis 230 

muscles , 222 

premonitory 217 

pulse 219, 224 

respiration 226 

somnolence 222 

temperature 218, 223 

tongue 218 

urine ..227 

treatment of 243, 255 

' ' cold applications 249 

" diet 254 

u digitalis 253 

" fresh air 247 

' ' hydrate of chloral 253 

' ' opium 253 

" phosphorus 253 

" prophylactic 244-246 

" stimulants 250-252 

' ' sulphate of quinine 248 

" tents 247 

' ' valerian 253 



Urine, changes in the, in miliary fever 361 

" " scarlet fever 312 

" " simple intermittent fever 122, 123 

" " typhoid fever 34 

u " typho-malarial fever « 191 



INDEX. 



408 



PAGE 

Urine, changes in the, in typhus fever 227 

" " yellow fever 97 

Vaccination . . . 295-300 

Valerian in the treatment of typhus fever 253 

Vapor inhalations in the treatment of measles 352 

" " typhoid fever 79 

Varioloid 300-302 

Vomiting in miliary fever 361 

" pernicious fever 151, 159 

" relapsing fever 261 

" scarlet fever 311 

" simple intermittent fever 123 

" ' ' remittent fever 13 7 

" small-pox 276 

" yellow fever 96 

Warbefg's tincture, formula for 166 



Yellow fever. 



definition of 

differential diagnosis of 

etiology of 

morbid anatomy of 

blood changes. 



55-106 
.. 85 
100 
88-93 
85-88 
. 88 



So 



88 
88 



brain 87 

heart 86, 87 

kidneys 87 

liver 

lungs 

mucous membrane 

skin 

spleen 

symptoms of 93-100 

" black vomit 96 

" delirium 98 

" jaundice 98 

" pulse , 95 

' ' temperature 93, 94 

" tongue 96 

' ' urine 97 

' ' vomiting 96 

prognosis of 102 

treatment of 103-106 



